LPHA completing IMN Form, must check the appropriate box below: LPHA met with the beneficiary LPHA met with the SUD counselor that conducted the intake SUD ICD-10 SUD Written Basis for Code: DSM-5 ICD-10 Diagnosis (Must be Name: Code: completed by LPHA & Codes: include specific criteria of Medi-Cal included primary Name: SUD diagnosis): Indicate all ASAM Levels of Care recommended: LPHA LPHA LPHA ASAM Is this level of care of ASAM recommendation Care: Level ASAM different than the of Level previously assessed Care: of ALOC? Yes No Care: Explain if yes: Client Information that has been considered includes the following: The beneficiary’s • personal, medical and substance use history; review of information with the client and/or LPHA *Physical Exam (when • available)
LPHA completing IMN Form, must check the appropriate box below: LPHA met with the beneficiary LPHA met with the SUD counselor that conducted the intake SUD ICD-10 Code: SUD DSM-5 Name: ICD-10 Code: Name: Codes: Written Basis for Diagnosis (Must be completed by LPHA & include specific criteria of Medi-Cal included primary SUD diagnosis): Indicate all ASAM Levels of Care recommended: LPHA ASAM of Care: LPHA ASAM Level of Care: LPHA ASAM Level of Care: Is this level of care recommendation different than the previously assessed ALOC? Yes No Explain if yes: Client Information that has been considered includes the following: • The beneficiary’s personal, medical and substance use history; review of information with the client and/or LPHA • *Physical Exam (when available)
Initial_Med_Nec_Form.docx