Behavioral Health Treatment Plan Form

*Required fields.

Instructions:

This form is for members who require an authorization for behavioral health outpatient treatment.  Submit this form to Regence for authorization of continued services.

Please call Regence Behavioral Health Customer Service at 1 (800) 780-7881 for any authorization questions.

Behavioral Health Treatment Plan Form

*Required fields.

Instructions:

This form is for members who require an authorization for behavioral health outpatient treatment.  Submit this form to Regence for authorization of continued services.

For treatment plan and authorization questions only, please call Regence Behavioral Health Customer Service at 1 (800) 780-7881.


Patient Information

Please enter patient information:    
Patient last name:*
 
Patient first name:*
 
Patient middle initial:
 
Patient DOB:*
MM/DD/YY
Patient's identification number:*
ID number from member card
Patient's Regence Group Number:
Group number from member card
     

Please enter provider information:    
Provider name:*
Last, First, MI
Tax ID number:*
 
NPI number:*

 

Phone number:*
 
Fax number:*
 
Requested Start Date of Authorization:* MM/DD/YY
     
Who should we contact if we require additional information?    
Contact Name:*
 
Contact Phone:*
 
Email:*
 
 

Physical  address where service will occur:    
Office street address:*
(include suite number)
Office street address line 2:
(include suite number)
City, State, Zip:*
 
     

I. Diagnosis - Use DSM-5    
DX:  
DX (personality):  
DX (medical conditions):  
Psychosocial Stressors:  

II. Current Risk Factors: Check all that apply and explain in presenting symptoms section
Suicidal/Homocidal Ideation:
None
1
2 3 4 5 Severe
Safety Plan:



 
Substance Abuse:
 
Drug of Choice:  
Functional Impairments:*
Other*

*Describe Other:

     

III. Treatment Information: Current Episode
     
First date of service:*
 
Number of sessions to date:*
 
Number of sessions requested at this time:*
 
Frequency to date:*  
Frequency Requested:*  
Modality requested:*
   
   
  #  
  #  
   
  90837 #  
  90846 #  
  90847 #  
  90853 #  
  +90785 #  
  90839 #  
  +90840 #  
     
Other Prescriber Modality requested:*    
   
   
   
   
   
     
Type of plan:*
 
     
Identify referrals made (adjunctive therapy, community resources):
 
     
Have you coordinated care with PCP?*
 
     
With other providers?*
Specify - add comments



IV. Medications, prescribed by:

   
   
   
   
Current (dosage & length of time on medication)  

V. Reason for Treatment/Presenting Symptoms:
     
Include relevant history and personal resources:*  
     
Treatment Goals (Behaviorally defined and progress made toward each goal):*
 
   
Termination Criteria (observable, measurable, and related to symptoms):*
 
   
Estimated number of sessions to termination of current episode of treatment:*
 

Name of authorized signer:*
Licensure:*
Date:*