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INSTRUCTIONS: Please print all information. Fax completed form to (877) 521-4787 (toll-free).

PATIENT Name PROVIDER Individual and/or Group Name Address ICD-9 DIAGNOSIS numeric + description Axis I Axis II Axis III Axis IV Axis V current CURRENT RISK ASSESSMENT Suicidal Ideation Homicidal Ideation MEDICATIONS Medication highest past year Plan Plan Psychotropic Intent Intent Medical Hx of harming self Hx of harming others Prescribing MD N/A N/A PCP Psychiatrist Other ID # DOB

Tax ID # City

License # State ZIP MEDICAL CONDITIONS None Asthma/COPD Cancer Cardiovascular Problems Other

Phone # Fax # Chronic Pain Dementia Diabetes Obesity

If affective or psychotic disorder is present and no medications are prescribed, please explain: COORDINATION OF CARE TREATMENT HISTORY I have communicated with patient's Inpatient: Within past yr PCP Specialist Psychiatrist Therapist Outpatient: Within past yr SYMPTOMS and FUNCTIONAL IMPAIRMENT If present, check degree On Disability? Yes

Mild Moderate Severe Mild Moderate Severe

1 to 3 yrs ago 1 to 3 yrs ago No

More than 3 yrs ago More than 3 yrs ago

Mild Moderate Severe

Anxiety Hopelessness Decreased Energy ADLs Delusions Family/Relationships Depressed Mood Inattention Hallucinations Irritability/Mood instability Hyperactivity Impulsivity Substance Abuse/Dependence Active In Remission If Substance Abuse is current or focus of treatment, complete the information below: Substance of Choice Amount Frequency Alcohol Marijuana Heroin Opioids Cocaine list Methamphetamine Prescr. Drugs Inhalants list DESIRED OBSERVABLE OUTCOMES

Obsessions/Compulsions Significant Weight Change Panic Attacks Sleep Disturbance Physical Health Work/School

Date of Last Use Is patient currently participating in a community-based support group? (Includes AA, NA, etc.) Yes No If Yes, frequency of attendance:

Is there a sponsor? Yes

Yes No


Patient agrees with treatment goals

PROVIDER'S CONTINUED TREATMENT PLAN Modality and CPT Code Frequency Individual 90804 ____ x per wk Ind. w/ Med Mgmt 90805 ____ x per wk Individual 90806 ____ x per wk Ind. w/ Med Mgmt 90807 ____ x per wk Couple/Family 90847 ____ x per wk Group 90853 ____ x per wk Medication Mgmt 90862 ____ x per wk Other _____________ ____ x per wk

Anthem Blue Cross P.O. Box 600188 San Diego, CA 92160

mo mo mo mo mo mo mo mo

yr yr yr yr yr yr yr yr

Anticipated Completion ____ mo(s) ____ mo(s) ____ mo(s) ____ mo(s) ____ mo(s) ____ mo(s) ____ mo(s) ____ mo(s)

TREATMENT PROGRESS Level of improvement to date Minor Moderate Major No progress to date Maintenance tx of chronic condition # of sessions provided to date Start date for new authorization My signature confirms that I am providing the requested services.



CA-2012-06 Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ® Anthem is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.


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