Current Diagnoses: Please attach most recent Psychiatric Note or Evaluation Psychiatric Diagnoses: Medical Diagnoses: What are the member’s current medications? Please attach most recent medication sheet/MARS. Psychotropic Medications with Directions Medical Medications with Directions Discharge Planning Update: What is the targeted level of functioning for the member to be considered ready for discharge? This must be in observable, measurable terms. Please attach most recent discharge plan. How does the member’s current level of functioning prevent him/her from returning to in-network outpatient services and supports? How many more units of service are being requested to reach the targeted level of functioning? What is the specific discharge plan? Include the specific planned outpatient services and supports and their frequency after discharge. Are there any barriers to implementing the discharge plan at this time? If yes, list the specific barrier(s) and outline the intervention(s) planned to remove it/them. Submit completed form with a copy of the current Individual Service Plan and OON progress notes by secure fax to 1-866-601-0111
Current Diagnoses: Please attach most recent Psychiatric Note or Evaluation Psychiatric Diagnoses: Medical Diagnoses: What are the member’s current medications? Please attach most recent medication sheet/MARS. Psychotropic Medications with Directions Medical Medications with Directions Discharge Planning Update: What is the targeted level of functioning for the member to be considered ready for discharge? This must be in observable, measurable terms. Please attach most recent discharge plan. How does the member’s current level of functioning prevent him/her from returning to in-network outpatient services and supports? How many more units of service are being requested to reach the targeted level of functioning? What is the specific discharge plan? Include the specific planned outpatient services and supports and their frequency after discharge. Are there any barriers to implementing the discharge plan at this time? If yes, list the specific barrier(s) and outline the intervention(s) planned to remove it/them. Submit completed form with a copy of the current Individual Service Plan and OON progress notes by secure fax to 1-866-601-0111
PMF_3-17-8.docx