Follow the steps to complete the form seamlessly.

1. Click the ‘Get Form’ button to obtain the form and open it in your editing program.
2. Begin by entering the member's details, including their name, member number, and date of birth in the designated fields.
3. Input the treating clinician's information. Specify their type, such as MD/DO or licensed psychologist, and provide their name.
4. Indicate the authorization type by selecting whether it is for an individual or an organization, and fill in the corresponding NPI numbers where required.
5. Provide the street address, place of service, city, ZIP code, and phone number of the treating clinician or organization.
6. Document the member's treatment history and total cumulative time in treatment, both with the current practitioner and with all practitioners.
7. Specify the current frequency of therapy sessions and the therapy modality being utilized, such as CBT or DBT.
8. Fill out the member's current DSM-5 diagnosis, including diagnosis codes and descriptions, and any related medical concerns.
9. Detail the current psychiatric medication management, including the prescriber’s information and current medications.
10. Complete the treatment adherence section by answering questions about the member’s engagement with treatment and homework assignments.
11. Indicate the desired target discharge date and the number of additional sessions requested.
12. Once all sections are complete, review the form for accuracy, then save your changes and download, print, or share the form as needed.

Start completing your BCN Behavioral Health Continuing OTR Form online today!