Form39 - [FORM 39-Use the top of this page for your...

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[ FORM 39 —Use the top of this page for your letterhead.] Individualized Behavioral/Mental Health Treatment Plan This is for q Preauthorization for initial certification q Concurrent review for reauthorization of care Date current episode of treatment began: Date of last plan: A. Identification Client’s name: Soc.Sec.#: ID #: Membership #: Date of birth: Sex: Group name/#: Certificate #: Name of subscriber/member,and address (if other than client): Release-of-records form(s) signed: q Yes q Not yet B. Administrative 1. Case manager’s additional suggestions for treatments and resources: Date Name Suggestions 2. Services: Sessions requested CPT code Date of request Start of sessions Number of ses- sions authorized Date of authorization Date of next review C. Present level of functioning/limitations/impairment (describe specific impairments at left, and rate degree of functional impairment at right with GAF number [100 = none, 70 = little, 30 = significant, 10 = incapacitated] or use descriptors): Area of functioning GAF rating 1. School/work functioning: 2. Intimate relationship/marriage: (cont.) FORM 39. Individualized treatment plan for managed care organizations (p. 1 of 4).
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This note was uploaded on 07/01/2010 for the course COUN 6682 A and taught by Professor All during the Spring '10 term at Walden University.

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Form39 - [FORM 39-Use the top of this page for your...

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