Get ValueOptions Outpatient Discharge Form 2008-2024

OUTPATIENT DISCHARGE FORM Please complete and submit this Discharge Form for your ValueOptions patient as soon as you confirm a Discharge Date. For example if this is an unplanned patientdirected discharge submit this form as soon as you are aware of the fact that your patient has discontinued using your services. Actual Discharge Date // Type of Service Mental Health Substance Abuse Patient s risk to self Patient Name Date of Birth Age M F Address City/State only Tel Patient s Insurance ID Patient s Employer/Benefit Plan Provider Name License Provider Program/Clinic if applicable VO Provider if known Service Address Tel City/State/Zip Licensure level type of license Are you independently licensed to provide services in the State where you are treating this patient Yes No ID Check Which SSN Tax ID NPI Primary Discharge DSM-IV Diagnosis Discharge Condition Improved No Change Type of Discharge Planned Worse Current Risk Assessment Scale 0 none 1 mild ideation only 2 moderate ideation with EITHER plan or history of attempts 3 severe ideation AND plan with either intent or means na not assessed Please select/circle one value for each type of risk With Ideation Intent Plan Means 0 1 2 3 na Current Impairments Please select/circle one value for each type of impairment 3 severe or severely incapacitating Mood Disturbance Depression or Mania Anxiety na Psychosis/Hallucinations/Delusions Thinking/Cognition/Memory/Concentration Problems Impulsive/Reckless/Aggressive Behavior Activities of Daily Living Problems Weight Change Associated with a Behavioral Diagnosis Medical/Physical Condition Job/School Performance Problems Social/Relationship/Marital/Family Problems Legal Problems Unplanned Discharge Reasons Check all that apply No further treatment indicated/stable Chose to disengage at this time Medication Management follow-up only Required more intensive services Chose other outpatient provider/service No longer eligible Moved Unable to contact Other Unknown Treating Provider s Signature Date ValueOptions 2005 Rev. 1. For example if this is an unplanned patientdirected discharge submit this form as soon as you are aware of the fact that your patient has discontinued using your services. Actual Discharge Date // Type of Service Mental Health Substance Abuse Patient s risk to self Patient Name Date of Birth Age M F Address City/State only Tel Patient s Insurance ID Patient s Employer/Benefit Plan Provider Name License Provider Program/Clinic if applicable VO Provider if known Service Address Tel City/State/Zip Licensure level type of license Are you independently licensed to provide services in the State where you are treating this patient Yes No ID Check Which SSN Tax ID NPI Primary Discharge DSM-IV Diagnosis Discharge Condition Improved No Change Type of Discharge Planned Worse Current Risk Assessment Scale 0 none 1 mild ideation only 2 moderate ideation with EITHER plan or history of attempts 3 severe ideation AND plan with either intent or means na not assessed Please select/circle one value for each type of risk With Ideation Intent Plan Means 0 1 2 3 na Current Impairments Please select/circle one value for each type of impairment 3 severe or severely incapacitating Mood Disturbance Depression or Mania Anxiety na Psychosis/Hallucinations/Delusions Thinking/Cognition/Memory/Concentration Problems Impulsive/Reckless/Aggressive Behavior Activities of Daily Living Problems Weight Change Associated with a Behavioral Diagnosis Medical/Physical Condition Job/School Performance Problems Social/Relationship/Marital/Family Problems Legal Problems Unplanned Discharge Reasons Check all that apply No further treatment indicated/stable Chose to disengage at this time Medication Management follow-up only Required more intensive services Chose other outpatient provider/service No longer eligible Moved Unable to contact Other Unknown Treating Provider s Signature Date ValueOptions 2005 Rev* 1. .