Conversely, injection forms, though being painful and needing help of medical personnel for application, help to quickly achieve necessary concentration of preparation in blood doxycycline online Antibiotic is usually chosen in an empiric way (at random). But when choosing one is obligatory guided by definite rules.

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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H1N1 Flu (Swine Flu)  General Information The Facts Swine influenza, also called “swine flu,” is a contagious respiratory disease that affects pigs. Just like humans, pigs can get the flu. The swine flu can be passed from pig to pig by direct contact, indirect contact (e.g., a pig coming in contact with a surface that has the virus), or through tiny particles in the air. Strain

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