Outpatient Review Form - Kentucky
Please Fax to Beacon at 1-800-441-2281

Provider Information	
Agency Name:  	 Provider ID:_
Clinician Name:  		 Phone #:                                                                    Ext:  		  Fax#:  		
		IMPACT Plus Provider	

Member Information (verify eligibility before rendering services)

Current Risk Indicators (check all that apply	
Current substance abuse              Fire setting
Caring for ill family member      Impulsive behavior Self-mutilation/cutting                Assaultive behavior Sexually offending behavior      Psychotic symptoms Current family violence (abuse, domestic)
Coping with significant loss (job, relationship, financial) Other:_ 		
Risk Assessment (check all that apply)	
Suicidal Tendency:
Not present         ideation        plan       means        prior attempt (date):  	
Homicidal Tendency:
Not present         ideation        plan       means        prior attempt (date):  	
Rate  member’s  level  of  psychological  distress:
1 (minimal)       2 (mild)       3 (moderate)      marked severe
Current Risk of Psychiatric Hospitalization:
1 (low)       2        3         4          5 (high). If 3 or higher, explain:  		

Member Name:_ 	

Health Plan Passport Humana/CareSource

Request is: Initial

Member ID:

DOB:  	

_                      Concurrent

Current Psychotropic  Medications	
Are Psychotropic Meds being prescribed?      Yes      No
Unknown
If yes, prescribed by :      MD       RN, CS/NP      PCP
Prescriber:  	 List of Meds:  	 
_ Is Member currently compliant with meds?       Yes       No
Is the Member court order to treatment?            Yes       No
Is the Member SPMI or SED?                            Yes       No	
DSM-IV Diagnosis	
Axis I: Axis II: Axis III:
Axis
IV: 	    GAF (0-100):                                         HGAF:  	 Have  you  communicated  with  member’s  PCP  in  past 12 months?
Yes     No  With the prescriber?     Yes        No       N/A	
Treatment Status	
(Please rate  the  member’s  response  to  treatment  since  last  review  or  
since start of treatment if this is first report.) Behavioral Symptoms that are focus of treatment:
Much Worse      Slightly     Worse      No Changes      Slight
Improvement     Major Improvement
Ability to perform work/school/household tasks:
Much Worse      Slightly     Worse      No Changes      Slight
Improvement     Major Improvement	

Status of the three most significant targeted goals since treatment initiation using the following scale:	
N = New Goal   1 = Much Worse     2= Somewhat Worse     3= No Change    4= Slight Improvement
5= Major Improvement    R= Resolved	
Goal	Modality
(Indiv/Grp/Hm/Collateral)	Progress (since tx initiation – indicate rating #	
1.			
2.			
3.			

Previous Treatment: Please indicate total number in last 12 months:	
	IP Admits	OP Visits	PHP/IOP/Day Tx	
Mental Health				
Substance Abuse				

Service	# of Units	Start Date	Anticipated Completion Date	Frequency of sessions:	
Diagnostic Interview					
Individual Therapy					
Individual w/ med management					
Family Therapy					

Request for Services- Traditional Outpatient:

Service	# of Units	Start Date	Anticipated Completion Date	Frequency of sessions:	
Therapeutic Rehabilitation/Day Tx					
Therapeutic Behavioral Services
(under 21)					
Targeted Case Management					
Personal Care Services					
Home Visit/Wrap					
Community Psychiatric Support					

Request for Services- Community Support Services – IF UNABLE TO USE eSERVICES

Service	# of Units	Start Date	Sessions over the next (30,
60 90 days)	Provider Rendering Service	
Targeted Care Management					
Behavioral Health Evaluation					
Therapeutic Child Support
(professional)					
Therapeutic Child Support (para-
professional)					
Parent-to-Parent Service					
After School Program					
Summer School Program					
Intensive Outpatient					
Day Treatment					
Partial Hospitalization					
Individual Therapy					
Individual Therapy with MD					
Individual OR Collateral Therapy (for
professionals under supervision)					
Group Therapy					
Collateral Service					

Request for Services- IMPACT Plus ONLY – please submit Collaborative Service Plan along with request for services