Get Wi Behavioral Health Outpatient Treatment Request Form 2013-2025
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How to fill out the WI Behavioral Health Outpatient Treatment Request Form online
Filling out the WI Behavioral Health Outpatient Treatment Request Form online is an important step in seeking necessary behavioral health treatment. This guide will provide clear, step-by-step instructions on how to complete each section of the form accurately and efficiently.
Follow the steps to complete your treatment request form online
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Begin by filling out your member information. This includes selecting your plan: Molina Medicaid, Molina Medicare, or Molina Marketplace. Indicate the request type, whether it is for initial or concurrent services, and provide the date of admission.
- Next, complete the provider information section. Include the provider, facility, or clinic name, the provider NPI or tax ID, contact information, and the clinician’s name and credentials.
- In the treatment history section, include details about your primary care physician, their contact information, and any relevant coordination of care information. Provide details about your current behavioral health provider and recent appointments.
- Specify the referral or service type requested by checking the appropriate boxes, which may include mental health services, substance abuse services, and other specialized treatments.
- Provide primary and additional diagnoses relevant to your treatment, outline psychosocial barriers, and indicate your level of functioning as assessed.
- In the presenting/current symptoms section, check any applicable symptoms affecting your treatment or discharge. Fill in any additional information to explain the symptoms further.
- If you are providing medication information, include the dosage and any changes from the time of admission.
- Fill out clinical information and treatment plan details. Include any required documentation, treatment progress, and specific needs relevant to your treatment plan.
- Review all completed sections for accuracy and completeness.
- Once you have filled out the form, you can save your changes, download, print, or share the completed form as needed.
Start completing your WI Behavioral Health Outpatient Treatment Request Form online today!
Outpatient care does not include services where patients are admitted to a hospital or residential facility for overnight stays. Emergency room visits, inpatient psychiatric care, and long-term residential treatment fall outside this category. Utilizing the WI Behavioral Health Outpatient Treatment Request Form can help you navigate and find the proper outpatient services that fit your needs.
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