Get Pain Programs Review Form - Healthpartners

The Pain Programs Review Form - HealthPartners is an essential document for those seeking approval for participation in multidisciplinary day treatment programs for chronic pain. This guide provides a step-by-step approach to filling out the form accurately and effectively.

Follow the steps to complete the form online with ease.

1. Click ‘Get Form’ button to acquire the Pain Programs Review Form - HealthPartners and open it in an appropriate editor.
2. Begin by entering the member name and member ID number in the specified fields. Ensure accuracy as this information is crucial for identification.
3. Fill in the patient's primary care physician's name and contact information, including clinic phone number and fax number.
4. Enter the name of the physician requesting authorization for the chronic pain program along with their clinic phone number and fax number.
5. In the section pertaining to the specific pain program requested, clearly state the name of the program.
6. Respond to the questions regarding the date of onset of the chronic pain syndrome, primary diagnosis, and dates associated with these conditions.
7. Detail the duration of care provided for the patient and confirm whether the patient has participated in an active physical therapy regimen in the past year.
8. Indicate if the patient has failed an active physical therapy program and provide explanations where necessary.
9. Answer the questions regarding any treatment the patient has received from a licensed mental health therapist specializing in chronic pain. Include the therapist's name if applicable.
10. List current medications that the patient is taking, ensuring to provide complete details for each.
11. Confirm whether the patient has been evaluated by a physician specializing in chronic pain in the past year.
12. Enumerate the medical interventions the patient has undergone, providing the name of the provider if available.
13. Describe the expected outcomes from the patient's participation in the program.
14. Confirm if the requesting physician will collaborate with the pain program post-treatment and provide details if another physician will follow the patient.
15. Finally, print the name, sign, and date the form. Ensure that the completed form is faxed back to Behavioral Health at the provided number.

Complete your Pain Programs Review Form - HealthPartners online today to ensure timely processing of your request.