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Microsoft word - bcbs treatment plan form.doc

TREATMENT PLAN
Fax Number: 1-205-220-0942
Precertification Number: 1-877-722-6084
PATIENT DEMOGRAPHICS

Date:_____________Was Patient Seen Today? _________Yes _________No Previous Date Patient Seen:__________________
Contract Number:____________________________________ Group Number:____________________________________________
Patient’s Name:_____________________________________________________________

Address:______________________________________________________________________State:_____________ZIP:_________
PROVIDER INFORMATOIN

Provider’s Name (Licensure):____________________________________________________________________________________
Address:______________________________________________________________________State:____________ZIP___________
Telephone #:____________________________Fax #:____________________________Tax ID #:____________________________
Date Provider Wishes Authorization to Start:_____________________Diagnosis:__________________________________________
Number of visits requested:_______________________
RISK ASSESSMENT/PATIENT CLINICAL INFORMATION

SUICIDE: ___________ Not Present___________ Ideation____________ Plan____________ Means____________ Prior Attempt

No Harm Contract:
_________Yes _________No Date of Last Ideation/attempt:_______________________________
HOMICIDE: __________ Not Present__________ Ideation____________ Plan____________ Means____________ Prior Attempt

No Harm Contract:
_________Yes _________No Date of Last Ideation/attempt:_______________________________
Mood Disturbances: _____ Depression_____ Mania_____ Hypomania_____ Anxiety Onset:________________________
Behavioral Disturbances: ______Recklessness_____ Impulsiveness______ Decline in functioning Onset:_______________
Eating Disorder Onset:______________________________ Dementia Onset:___________________________________________
Substance Abuse Onset:___________ Other (please give brief description):____________________________________________
Hallucinations: _______________ Auditory_______________ Visual______________ Command Onset:_______________
_______________ Delusions ______________ Paranoia Onset:_______________

Have symptoms affected the patient’s job/school, relationships and/or legal status? YES NO
If so, describe the situation:____________________________________________________________________________________
____________________________________________________________________________________________________________
MEDICATIONS
ADHD

NARCOLEPSY
ALZHEIMER’S/DEMENTIAS
_________Adderall
_________Providgal
__________ Aricept
_________Adderall XR _________Ritalin __________
_________Concerta
_________Straterra
_________Cylert
ANTIDIPRESSANTS
ANTICONVULSANTS/MOOD
STABILIZERS
_________Celexa
_________Paxil CR
_________Gabitril _________Depakote
_________Desyrel _________Prozac _________Lamictal _________Lithium
_________Effexor _________Remeron _________Neurontin
_________Tegretol
_________Effexor XR
_________Serzone _________Triliptal _________Topamax
_________Elavil
_________Cybalta
_________Lexapro _________Wellbutrin
ANTIPSYCHOTICS
_________Luvox
_________Wellbutrin SR
_________Haldol _________Geodon
_________Paxil
_________Zoloft
_________Prolixin
_________Risperdal
_________Thorazine
_________Seroquel
HYPNOTICS
_________Abilify
________Zyprexa
_________Restoril _________Clozaril
ANXIOLYTICS
_________Ativan
_________Atarax
_________Klonopin
_________BuSpar
_________Valium
_________Hydroxyzine
_________Xanax
_________Vistaril

TREATMENT
TREATMENT/MEDICATION COMPLIANCE ISSUES (PLEASE DESCRIBE):
______________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

Individual Therapy Group Therapy Family Therapy Medication Management ECT Substance Abuse
Other (please describe):
_______________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Please give a brief description of treatment goals, including target dates:______________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

Other Concerns:
_____________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Provider Signature:__________________________________________________________________________________________

Source: http://threecsystems.com/Managed%20Care%20forms/BCFEDOTR.pdf

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Medikamentöse Schmerztherapie E. Winter Schmerzzentrum Tutzing Medikamentöse Schmerztherapie „eigentliche“ Schmerzmittel Nicht-Opioide Medikamentöse Schmerztherapie „eigentliche“ Schmerzmittel Schwache Opioide Starke Opioide Medikamentöse Schmerztherapie WHO-Stufenschema Nicht-Opioide und starke Opioide Nicht-Opioide und schwache

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