Get Routine Outpatient Services

Filling out the Routine Outpatient Services form online is an important step in requesting necessary behavioral health services. This guide aims to provide clear and concise instructions to ensure you complete the form accurately and efficiently.

Follow the steps to complete the Routine Outpatient Services form online

1. Press the ‘Get Form’ button to access the Routine Outpatient Services form and open it in your preferred editing tool.
2. Begin by completing the 'Member Information' section. Enter the last name, first name, middle initial, date of birth, phone number, WellCare ID number, and gender. If applicable, indicate whether the member has third-party insurance.
3. In the 'Treating Provider/Practitioner Information' section, fill out the provider's last name, first name, WellCare ID number, NPI number, discipline or specialty, street address, city, state, ZIP code, phone number, and fax number.
4. Complete the 'Facility/Agency Information' section by entering the facility's name, street address, city, state, ZIP code, phone number, and relevant identifiers such as Facility ID and NPI number.
5. For 'Service Type Requested,' include relevant codes for the requested services. Specify the number of units requested, ensuring it does not exceed a three-month period.
6. In the 'Diagnosis – Code and Description' section, indicate both the primary and secondary diagnosis along with any associated medical problems.
7. Detail the treatment phase by selecting whether the request is for initiation, continuation, or stabilization/maintenance, and attach necessary documentation as required.
8. Provide descriptions of any risk factors and symptoms, including baseline behavior, inpatient admissions, and current severity ratings for various functional areas.
9. Narrative sections require you to explain treatment interventions and discharge goals for each functional area of concern, highlighting any necessary modifications to the treatment plan.
10. Indicate the member's adherence to therapy and medications, documenting any reasons for additional therapy sessions needed.
11. Finally, review your completed form for accuracy, save the changes, and you can download, print, or share the filled form as needed.

Complete your Routine Outpatient Services form online today.