Post on 30-Jul-2018
transcript
Page 1 of 8
BEHAVIORAL HEALTH LOB: QUEST ACAP
Service Type: MH CD Dual DX Auth Request Type: Standard Retro
1. Provider/Facility:______________________________________
Contact Person:_______________________________________
Big Island Maui Oahu
Molokai Kauai Lanai
Phone: Fax: Request Date:
2. 2. Member Name:____________________________________________ Member ID:_______________________ DOB:______/_____/_________ Age:________ __
3. DSM/ICD 10 Diagnostic Codes:
Primary:___________________________________________________
Secondary:_________________________________________________
_________________________________________________________
4. Medical Conditions:
________________________________________________________________
5. Z Codes: Please check areas of concern (if applicable):
Primary Support Group Legal System/Crime Housing Economic Social Environment Occupational Access to Care Educational
Other:_________________________________________________________
7. Requested # of Sessions:_______________________________________
From:_________________ _________To:___________________________
8. Required Documentation: Please submit required clinical notes for either 6A or 6Bas listed below:
A. Outpatient Mental Health: Clinical Summary Behavioral Contract (If applicable)
B. Chemical Dependency/Dual Diagnosis: UA results Behavioral Contract (If applicable)
9. If this is a Retro-‐request please explain why: ___________________________
____________________________________________________________________
6. Level of Care Requested:
Social Detox Res PHP IOP LIOP OPS Methadone Maintenance
8. 10. Current Medications: (psychiatric/other)
Medication Dose Frequency Start Date Prescriber
CONTINUING MENTAL HEALTH OUTPATIENT AND/OR CHEMICAL DEPENDENCY PRIOR AUTH REQUEST FORM
April 2016
Page 2 of 6
Does member require an Interpreter? Yes No If yes, what language : ___________________________________________________________________________
Is Care Coordination requested: Yes No (If yes, please explain):___________________________________________________________________________________
QUEST only: Potential SMI/SPMI/SEBD: Yes No
CLINICAL INFORMATION: (Please complete the following)
1. Please explain why member continues to require this Level of Care:______________________________________________________________________________
_____________________________________________________________________________________________________________________________________
2. Did member attend all scheduled sessions? Yes No If No, please list dates and reasons for non-‐attendance:______________________________________
_____________________________________________________________________________________________________________________________________
3. Date of most recent UA:___________________________________Results:________________________________________________________________________
If UA was not done, please explain why:____________________________________________________________________________________________________
4. Is member on a Behavior Contract? Yes No If yes, please explain why and attach a copy:
____________________________________________________________________________________________________________________________________
5. Does member attend any sober support meetings? Yes No
If yes, how many meeting per week:_______________________________________________________________________________________________________
If No, what is your plan to assist member in connecting to a sober support system in the community? __________________________________________________
____________________________________________________________________________________________________________________________________
6. Does member have a sponsor? Yes No If yes, How many contacts per week?_______________________________________________________________
7. Is member working on the 12 Steps? Yes No If yes, What step is member on?______________________________________________________________
8. Does member have a Sober Support Phone Tree? Yes No
If yes, how many #’s collected?____________________________ How often used?_________________________________________________________________
9. What is member’s current assignment?_____________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
10. Is member able to give feedback w/o being hurtful? __________________________________________________________________________________________
11. Is member able to take feedback w/o taking offense?__________________________________________________________________________________________
12. Any Significant insight/connections made? Any Behavior Changes? Yes No If yes, please explain:_______________________________________________
13. Has member learned coping skills? What skills? Please explain:__________________________________________________________________________________
April 2016
Page 2 of 6
Does member require an Interpreter? Yes No If yes, what language : ___________________________________________________________________________
Is Care Coordination requested: Yes No (If yes, please explain):___________________________________________________________________________________
QUEST only: Potential SMI/SPMI/SEBD: Yes No
CLINICAL INFORMATION: (Please complete the following)
1. Please explain why member continues to require this Level of Care:______________________________________________________________________________
_____________________________________________________________________________________________________________________________________
2. Did member attend all scheduled sessions? Yes No If No, please list dates and reasons for non-‐attendance:______________________________________
_____________________________________________________________________________________________________________________________________
3. Date of most recent UA:___________________________________Results:________________________________________________________________________
If UA was not done, please explain why:____________________________________________________________________________________________________
4. Is member on a Behavior Contract? Yes No If yes, please explain why and attach a copy:
____________________________________________________________________________________________________________________________________
5. Does member attend any sober support meetings? Yes No
If yes, how many meeting per week:_______________________________________________________________________________________________________
If No, what is your plan to assist member in connecting to a sober support system in the community? __________________________________________________
____________________________________________________________________________________________________________________________________
6. Does member have a sponsor? Yes No If yes, How many contacts per week?_______________________________________________________________
7. Is member working on the 12 Steps? Yes No If yes, What step is member on?______________________________________________________________
8. Does member have a Sober Support Phone Tree? Yes No
If yes, how many #’s collected?____________________________ How often used?_________________________________________________________________
9. What is member’s current assignment?_____________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
10. Is member able to give feedback w/o being hurtful? __________________________________________________________________________________________
11. Is member able to take feedback w/o taking offense?__________________________________________________________________________________________
12. Any Significant insight/connections made? Any Behavior Changes? Yes No If yes, please explain:_______________________________________________
13. Has member learned coping skills? What skills? Please explain:__________________________________________________________________________________
April 2016
Page 2 of 6
Does member require an Interpreter? Yes No If yes, what language : ___________________________________________________________________________
Is Care Coordination requested: Yes No (If yes, please explain):___________________________________________________________________________________
QUEST only: Potential SMI/SPMI/SEBD: Yes No
CLINICAL INFORMATION: (Please complete the following)
1. Please explain why member continues to require this Level of Care:______________________________________________________________________________
_____________________________________________________________________________________________________________________________________
2. Did member attend all scheduled sessions? Yes No If No, please list dates and reasons for non-‐attendance:______________________________________
_____________________________________________________________________________________________________________________________________
3. Date of most recent UA:___________________________________Results:________________________________________________________________________
If UA was not done, please explain why:____________________________________________________________________________________________________
4. Is member on a Behavior Contract? Yes No If yes, please explain why and attach a copy:
____________________________________________________________________________________________________________________________________
5. Does member attend any sober support meetings? Yes No
If yes, how many meeting per week:_______________________________________________________________________________________________________
If No, what is your plan to assist member in connecting to a sober support system in the community? __________________________________________________
____________________________________________________________________________________________________________________________________
6. Does member have a sponsor? Yes No If yes, How many contacts per week?_______________________________________________________________
7. Is member working on the 12 Steps? Yes No If yes, What step is member on?______________________________________________________________
8. Does member have a Sober Support Phone Tree? Yes No
If yes, how many #’s collected?____________________________ How often used?_________________________________________________________________
9. What is member’s current assignment?_____________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
10. Is member able to give feedback w/o being hurtful? __________________________________________________________________________________________
11. Is member able to take feedback w/o taking offense?__________________________________________________________________________________________
12. Any Significant insight/connections made? Any Behavior Changes? Yes No If yes, please explain:_______________________________________________
13. Has member learned coping skills? What skills? Please explain:__________________________________________________________________________________
April 2016
Page 2 of 6
Does member require an Interpreter? Yes No If yes, what language : ___________________________________________________________________________
Is Care Coordination requested: Yes No (If yes, please explain):___________________________________________________________________________________
QUEST only: Potential SMI/SPMI/SEBD: Yes No
CLINICAL INFORMATION: (Please complete the following)
1. Please explain why member continues to require this Level of Care:______________________________________________________________________________
_____________________________________________________________________________________________________________________________________
2. Did member attend all scheduled sessions? Yes No If No, please list dates and reasons for non-‐attendance:______________________________________
_____________________________________________________________________________________________________________________________________
3. Date of most recent UA:___________________________________Results:________________________________________________________________________
If UA was not done, please explain why:____________________________________________________________________________________________________
4. Is member on a Behavior Contract? Yes No If yes, please explain why and attach a copy:
____________________________________________________________________________________________________________________________________
5. Does member attend any sober support meetings? Yes No
If yes, how many meeting per week:_______________________________________________________________________________________________________
If No, what is your plan to assist member in connecting to a sober support system in the community? __________________________________________________
____________________________________________________________________________________________________________________________________
6. Does member have a sponsor? Yes No If yes, How many contacts per week?_______________________________________________________________
7. Is member working on the 12 Steps? Yes No If yes, What step is member on?______________________________________________________________
8. Does member have a Sober Support Phone Tree? Yes No
If yes, how many #’s collected?____________________________ How often used?_________________________________________________________________
9. What is member’s current assignment?_____________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
10. Is member able to give feedback w/o being hurtful? __________________________________________________________________________________________
11. Is member able to take feedback w/o taking offense?__________________________________________________________________________________________
12. Any Significant insight/connections made? Any Behavior Changes? Yes No If yes, please explain:_______________________________________________
13. Has member learned coping skills? What skills? Please explain:__________________________________________________________________________________
April 2016
Page 2 of 6
Does member require an Interpreter? Yes No If yes, what language : ___________________________________________________________________________
Is Care Coordination requested: Yes No (If yes, please explain):___________________________________________________________________________________
QUEST only: Potential SMI/SPMI/SEBD: Yes No
CLINICAL INFORMATION: (Please complete the following)
1. Please explain why member continues to require this Level of Care:______________________________________________________________________________
_____________________________________________________________________________________________________________________________________
2. Did member attend all scheduled sessions? Yes No If No, please list dates and reasons for non-‐attendance:______________________________________
_____________________________________________________________________________________________________________________________________
3. Date of most recent UA:___________________________________Results:________________________________________________________________________
If UA was not done, please explain why:____________________________________________________________________________________________________
4. Is member on a Behavior Contract? Yes No If yes, please explain why and attach a copy:
____________________________________________________________________________________________________________________________________
5. Does member attend any sober support meetings? Yes No
If yes, how many meeting per week:_______________________________________________________________________________________________________
If No, what is your plan to assist member in connecting to a sober support system in the community? __________________________________________________
____________________________________________________________________________________________________________________________________
6. Does member have a sponsor? Yes No If yes, How many contacts per week?_______________________________________________________________
7. Is member working on the 12 Steps? Yes No If yes, What step is member on?______________________________________________________________
8. Does member have a Sober Support Phone Tree? Yes No
If yes, how many #’s collected?____________________________ How often used?_________________________________________________________________
9. What is member’s current assignment?_____________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
10. Is member able to give feedback w/o being hurtful? __________________________________________________________________________________________
11. Is member able to take feedback w/o taking offense?__________________________________________________________________________________________
12. Any Significant insight/connections made? Any Behavior Changes? Yes No If yes, please explain:_______________________________________________
13. Has member learned coping skills? What skills? Please explain:__________________________________________________________________________________
April 2016
Page 2 of 6
Does member require an Interpreter? Yes No If yes, what language : ___________________________________________________________________________
Is Care Coordination requested: Yes No (If yes, please explain):___________________________________________________________________________________
QUEST only: Potential SMI/SPMI/SEBD: Yes No
CLINICAL INFORMATION: (Please complete the following)
1. Please explain why member continues to require this Level of Care:______________________________________________________________________________
_____________________________________________________________________________________________________________________________________
2. Did member attend all scheduled sessions? Yes No If No, please list dates and reasons for non-‐attendance:______________________________________
_____________________________________________________________________________________________________________________________________
3. Date of most recent UA:___________________________________Results:________________________________________________________________________
If UA was not done, please explain why:____________________________________________________________________________________________________
4. Is member on a Behavior Contract? Yes No If yes, please explain why and attach a copy:
____________________________________________________________________________________________________________________________________
5. Does member attend any sober support meetings? Yes No
If yes, how many meeting per week:_______________________________________________________________________________________________________
If No, what is your plan to assist member in connecting to a sober support system in the community? __________________________________________________
____________________________________________________________________________________________________________________________________
6. Does member have a sponsor? Yes No If yes, How many contacts per week?_______________________________________________________________
7. Is member working on the 12 Steps? Yes No If yes, What step is member on?______________________________________________________________
8. Does member have a Sober Support Phone Tree? Yes No
If yes, how many #’s collected?____________________________ How often used?_________________________________________________________________
9. What is member’s current assignment?_____________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
10. Is member able to give feedback w/o being hurtful? __________________________________________________________________________________________
11. Is member able to take feedback w/o taking offense?__________________________________________________________________________________________
12. Any Significant insight/connections made? Any Behavior Changes? Yes No If yes, please explain:_______________________________________________
13. Has member learned coping skills? What skills? Please explain:__________________________________________________________________________________
April 2016
Page 2 of 6
Does member require an Interpreter? Yes No If yes, what language : ___________________________________________________________________________
Is Care Coordination requested: Yes No (If yes, please explain):___________________________________________________________________________________
QUEST only: Potential SMI/SPMI/SEBD: Yes No
CLINICAL INFORMATION: (Please complete the following)
1. Please explain why member continues to require this Level of Care:______________________________________________________________________________
_____________________________________________________________________________________________________________________________________
2. Did member attend all scheduled sessions? Yes No If No, please list dates and reasons for non-‐attendance:______________________________________
_____________________________________________________________________________________________________________________________________
3. Date of most recent UA:___________________________________Results:________________________________________________________________________
If UA was not done, please explain why:____________________________________________________________________________________________________
4. Is member on a Behavior Contract? Yes No If yes, please explain why and attach a copy:
____________________________________________________________________________________________________________________________________
5. Does member attend any sober support meetings? Yes No
If yes, how many meeting per week:_______________________________________________________________________________________________________
If No, what is your plan to assist member in connecting to a sober support system in the community? __________________________________________________
____________________________________________________________________________________________________________________________________
6. Does member have a sponsor? Yes No If yes, How many contacts per week?_______________________________________________________________
7. Is member working on the 12 Steps? Yes No If yes, What step is member on?______________________________________________________________
8. Does member have a Sober Support Phone Tree? Yes No
If yes, how many #’s collected?____________________________ How often used?_________________________________________________________________
9. What is member’s current assignment?_____________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
10. Is member able to give feedback w/o being hurtful? __________________________________________________________________________________________
11. Is member able to take feedback w/o taking offense?__________________________________________________________________________________________
12. Any Significant insight/connections made? Any Behavior Changes? Yes No If yes, please explain:_______________________________________________
13. Has member learned coping skills? What skills? Please explain:__________________________________________________________________________________
April 2016
Page 2 of 6
Does member require an Interpreter? Yes No If yes, what language : ___________________________________________________________________________
Is Care Coordination requested: Yes No (If yes, please explain):___________________________________________________________________________________
QUEST only: Potential SMI/SPMI/SEBD: Yes No
CLINICAL INFORMATION: (Please complete the following)
1. Please explain why member continues to require this Level of Care:______________________________________________________________________________
_____________________________________________________________________________________________________________________________________
2. Did member attend all scheduled sessions? Yes No If No, please list dates and reasons for non-‐attendance:______________________________________
_____________________________________________________________________________________________________________________________________
3. Date of most recent UA:___________________________________Results:________________________________________________________________________
If UA was not done, please explain why:____________________________________________________________________________________________________
4. Is member on a Behavior Contract? Yes No If yes, please explain why and attach a copy:
____________________________________________________________________________________________________________________________________
5. Does member attend any sober support meetings? Yes No
If yes, how many meeting per week:_______________________________________________________________________________________________________
If No, what is your plan to assist member in connecting to a sober support system in the community? __________________________________________________
____________________________________________________________________________________________________________________________________
6. Does member have a sponsor? Yes No If yes, How many contacts per week?_______________________________________________________________
7. Is member working on the 12 Steps? Yes No If yes, What step is member on?______________________________________________________________
8. Does member have a Sober Support Phone Tree? Yes No
If yes, how many #’s collected?____________________________ How often used?_________________________________________________________________
9. What is member’s current assignment?_____________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
10. Is member able to give feedback w/o being hurtful? __________________________________________________________________________________________
11. Is member able to take feedback w/o taking offense?__________________________________________________________________________________________
12. Any Significant insight/connections made? Any Behavior Changes? Yes No If yes, please explain:_______________________________________________
13. Has member learned coping skills? What skills? Please explain:__________________________________________________________________________________
April 2016
Page 2 of 6
Does member require an Interpreter? Yes No If yes, what language : ___________________________________________________________________________
Is Care Coordination requested: Yes No (If yes, please explain):___________________________________________________________________________________
QUEST only: Potential SMI/SPMI/SEBD: Yes No
CLINICAL INFORMATION: (Please complete the following)
1. Please explain why member continues to require this Level of Care:______________________________________________________________________________
_____________________________________________________________________________________________________________________________________
2. Did member attend all scheduled sessions? Yes No If No, please list dates and reasons for non-‐attendance:______________________________________
_____________________________________________________________________________________________________________________________________
3. Date of most recent UA:___________________________________Results:________________________________________________________________________
If UA was not done, please explain why:____________________________________________________________________________________________________
4. Is member on a Behavior Contract? Yes No If yes, please explain why and attach a copy:
____________________________________________________________________________________________________________________________________
5. Does member attend any sober support meetings? Yes No
If yes, how many meeting per week:_______________________________________________________________________________________________________
If No, what is your plan to assist member in connecting to a sober support system in the community? __________________________________________________
____________________________________________________________________________________________________________________________________
6. Does member have a sponsor? Yes No If yes, How many contacts per week?_______________________________________________________________
7. Is member working on the 12 Steps? Yes No If yes, What step is member on?______________________________________________________________
8. Does member have a Sober Support Phone Tree? Yes No
If yes, how many #’s collected?____________________________ How often used?_________________________________________________________________
9. What is member’s current assignment?_____________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
10. Is member able to give feedback w/o being hurtful? __________________________________________________________________________________________
11. Is member able to take feedback w/o taking offense?__________________________________________________________________________________________
12. Any Significant insight/connections made? Any Behavior Changes? Yes No If yes, please explain:_______________________________________________
13. Has member learned coping skills? What skills? Please explain:__________________________________________________________________________________
April 2016
Page 2 of 6
Does member require an Interpreter? Yes No If yes, what language : ___________________________________________________________________________
Is Care Coordination requested: Yes No (If yes, please explain):___________________________________________________________________________________
QUEST only: Potential SMI/SPMI/SEBD: Yes No
CLINICAL INFORMATION: (Please complete the following)
1. Please explain why member continues to require this Level of Care:______________________________________________________________________________
_____________________________________________________________________________________________________________________________________
2. Did member attend all scheduled sessions? Yes No If No, please list dates and reasons for non-‐attendance:______________________________________
_____________________________________________________________________________________________________________________________________
3. Date of most recent UA:___________________________________Results:________________________________________________________________________
If UA was not done, please explain why:____________________________________________________________________________________________________
4. Is member on a Behavior Contract? Yes No If yes, please explain why and attach a copy:
____________________________________________________________________________________________________________________________________
5. Does member attend any sober support meetings? Yes No
If yes, how many meeting per week:_______________________________________________________________________________________________________
If No, what is your plan to assist member in connecting to a sober support system in the community? __________________________________________________
____________________________________________________________________________________________________________________________________
6. Does member have a sponsor? Yes No If yes, How many contacts per week?_______________________________________________________________
7. Is member working on the 12 Steps? Yes No If yes, What step is member on?______________________________________________________________
8. Does member have a Sober Support Phone Tree? Yes No
If yes, how many #’s collected?____________________________ How often used?_________________________________________________________________
9. What is member’s current assignment?_____________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
10. Is member able to give feedback w/o being hurtful? __________________________________________________________________________________________
11. Is member able to take feedback w/o taking offense?__________________________________________________________________________________________
12. Any Significant insight/connections made? Any Behavior Changes? Yes No If yes, please explain:_______________________________________________
13. Has member learned coping skills? What skills? Please explain:__________________________________________________________________________________
April 2016
Page 2 of 6
Does member require an Interpreter? Yes No If yes, what language : ___________________________________________________________________________
Is Care Coordination requested: Yes No (If yes, please explain):___________________________________________________________________________________
QUEST only: Potential SMI/SPMI/SEBD: Yes No
CLINICAL INFORMATION: (Please complete the following)
1. Please explain why member continues to require this Level of Care:______________________________________________________________________________
_____________________________________________________________________________________________________________________________________
2. Did member attend all scheduled sessions? Yes No If No, please list dates and reasons for non-‐attendance:______________________________________
_____________________________________________________________________________________________________________________________________
3. Date of most recent UA:___________________________________Results:________________________________________________________________________
If UA was not done, please explain why:____________________________________________________________________________________________________
4. Is member on a Behavior Contract? Yes No If yes, please explain why and attach a copy:
____________________________________________________________________________________________________________________________________
5. Does member attend any sober support meetings? Yes No
If yes, how many meeting per week:_______________________________________________________________________________________________________
If No, what is your plan to assist member in connecting to a sober support system in the community? __________________________________________________
____________________________________________________________________________________________________________________________________
6. Does member have a sponsor? Yes No If yes, How many contacts per week?_______________________________________________________________
7. Is member working on the 12 Steps? Yes No If yes, What step is member on?______________________________________________________________
8. Does member have a Sober Support Phone Tree? Yes No
If yes, how many #’s collected?____________________________ How often used?_________________________________________________________________
9. What is member’s current assignment?_____________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
10. Is member able to give feedback w/o being hurtful? __________________________________________________________________________________________
11. Is member able to take feedback w/o taking offense?__________________________________________________________________________________________
12. Any Significant insight/connections made? Any Behavior Changes? Yes No If yes, please explain:_______________________________________________
13. Has member learned coping skills? What skills? Please explain:__________________________________________________________________________________
April 2016
Page 2 of 6
Does member require an Interpreter? Yes No If yes, what language : ___________________________________________________________________________
Is Care Coordination requested: Yes No (If yes, please explain):___________________________________________________________________________________
QUEST only: Potential SMI/SPMI/SEBD: Yes No
CLINICAL INFORMATION: (Please complete the following)
1. Please explain why member continues to require this Level of Care:______________________________________________________________________________
_____________________________________________________________________________________________________________________________________
2. Did member attend all scheduled sessions? Yes No If No, please list dates and reasons for non-‐attendance:______________________________________
_____________________________________________________________________________________________________________________________________
3. Date of most recent UA:___________________________________Results:________________________________________________________________________
If UA was not done, please explain why:____________________________________________________________________________________________________
4. Is member on a Behavior Contract? Yes No If yes, please explain why and attach a copy:
____________________________________________________________________________________________________________________________________
5. Does member attend any sober support meetings? Yes No
If yes, how many meeting per week:_______________________________________________________________________________________________________
If No, what is your plan to assist member in connecting to a sober support system in the community? __________________________________________________
____________________________________________________________________________________________________________________________________
6. Does member have a sponsor? Yes No If yes, How many contacts per week?_______________________________________________________________
7. Is member working on the 12 Steps? Yes No If yes, What step is member on?______________________________________________________________
8. Does member have a Sober Support Phone Tree? Yes No
If yes, how many #’s collected?____________________________ How often used?_________________________________________________________________
9. What is member’s current assignment?_____________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
10. Is member able to give feedback w/o being hurtful? __________________________________________________________________________________________
11. Is member able to take feedback w/o taking offense?__________________________________________________________________________________________
12. Any Significant insight/connections made? Any Behavior Changes? Yes No If yes, please explain:_______________________________________________
13. Has member learned coping skills? What skills? Please explain:__________________________________________________________________________________
April 2016
Page 2 of 6
Does member require an Interpreter? Yes No If yes, what language : ___________________________________________________________________________
Is Care Coordination requested: Yes No (If yes, please explain):___________________________________________________________________________________
QUEST only: Potential SMI/SPMI/SEBD: Yes No
CLINICAL INFORMATION: (Please complete the following)
1. Please explain why member continues to require this Level of Care:______________________________________________________________________________
_____________________________________________________________________________________________________________________________________
2. Did member attend all scheduled sessions? Yes No If No, please list dates and reasons for non-‐attendance:______________________________________
_____________________________________________________________________________________________________________________________________
3. Date of most recent UA:___________________________________Results:________________________________________________________________________
If UA was not done, please explain why:____________________________________________________________________________________________________
4. Is member on a Behavior Contract? Yes No If yes, please explain why and attach a copy:
____________________________________________________________________________________________________________________________________
5. Does member attend any sober support meetings? Yes No
If yes, how many meeting per week:_______________________________________________________________________________________________________
If No, what is your plan to assist member in connecting to a sober support system in the community? __________________________________________________
____________________________________________________________________________________________________________________________________
6. Does member have a sponsor? Yes No If yes, How many contacts per week?_______________________________________________________________
7. Is member working on the 12 Steps? Yes No If yes, What step is member on?______________________________________________________________
8. Does member have a Sober Support Phone Tree? Yes No
If yes, how many #’s collected?____________________________ How often used?_________________________________________________________________
9. What is member’s current assignment?_____________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
10. Is member able to give feedback w/o being hurtful? __________________________________________________________________________________________
11. Is member able to take feedback w/o taking offense?__________________________________________________________________________________________
12. Any Significant insight/connections made? Any Behavior Changes? Yes No If yes, please explain:_______________________________________________
13. Has member learned coping skills? What skills? Please explain:__________________________________________________________________________________
April 2016
Page 2 of 6
Does member require an Interpreter? Yes No If yes, what language : ___________________________________________________________________________
Is Care Coordination requested: Yes No (If yes, please explain):___________________________________________________________________________________
QUEST only: Potential SMI/SPMI/SEBD: Yes No
CLINICAL INFORMATION: (Please complete the following)
1. Please explain why member continues to require this Level of Care:______________________________________________________________________________
_____________________________________________________________________________________________________________________________________
2. Did member attend all scheduled sessions? Yes No If No, please list dates and reasons for non-‐attendance:______________________________________
_____________________________________________________________________________________________________________________________________
3. Date of most recent UA:___________________________________Results:________________________________________________________________________
If UA was not done, please explain why:____________________________________________________________________________________________________
4. Is member on a Behavior Contract? Yes No If yes, please explain why and attach a copy:
____________________________________________________________________________________________________________________________________
5. Does member attend any sober support meetings? Yes No
If yes, how many meeting per week:_______________________________________________________________________________________________________
If No, what is your plan to assist member in connecting to a sober support system in the community? __________________________________________________
____________________________________________________________________________________________________________________________________
6. Does member have a sponsor? Yes No If yes, How many contacts per week?_______________________________________________________________
7. Is member working on the 12 Steps? Yes No If yes, What step is member on?______________________________________________________________
8. Does member have a Sober Support Phone Tree? Yes No
If yes, how many #’s collected?____________________________ How often used?_________________________________________________________________
9. What is member’s current assignment?_____________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
10. Is member able to give feedback w/o being hurtful? __________________________________________________________________________________________
11. Is member able to take feedback w/o taking offense?__________________________________________________________________________________________
12. Any Significant insight/connections made? Any Behavior Changes? Yes No If yes, please explain:_______________________________________________
13. Has member learned coping skills? What skills? Please explain:__________________________________________________________________________________
April 2016
April 2016 Page 2 of 8
Page 2 of 6
Does member require an Interpreter? Yes No If yes, what language : ___________________________________________________________________________
Is Care Coordination requested: Yes No (If yes, please explain):___________________________________________________________________________________
QUEST only: Potential SMI/SPMI/SEBD: Yes No
CLINICAL INFORMATION: (Please complete the following)
1. Please explain why member continues to require this Level of Care:______________________________________________________________________________
_____________________________________________________________________________________________________________________________________
2. Did member attend all scheduled sessions? Yes No If No, please list dates and reasons for non-‐attendance:______________________________________
_____________________________________________________________________________________________________________________________________
3. Date of most recent UA:___________________________________Results:________________________________________________________________________
If UA was not done, please explain why:____________________________________________________________________________________________________
4. Is member on a Behavior Contract? Yes No If yes, please explain why and attach a copy:
____________________________________________________________________________________________________________________________________
5. Does member attend any sober support meetings? Yes No
If yes, how many meeting per week:_______________________________________________________________________________________________________
If No, what is your plan to assist member in connecting to a sober support system in the community? __________________________________________________
____________________________________________________________________________________________________________________________________
6. Does member have a sponsor? Yes No If yes, How many contacts per week?_______________________________________________________________
7. Is member working on the 12 Steps? Yes No If yes, What step is member on?______________________________________________________________
8. Does member have a Sober Support Phone Tree? Yes No
If yes, how many #’s collected?____________________________ How often used?_________________________________________________________________
9. What is member’s current assignment?_____________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
10. Is member able to give feedback w/o being hurtful? __________________________________________________________________________________________
11. Is member able to take feedback w/o taking offense?__________________________________________________________________________________________
12. Any Significant insight/connections made? Any Behavior Changes? Yes No If yes, please explain:_______________________________________________
13. Has member learned coping skills? What skills? Please explain:__________________________________________________________________________________
April 2016
Page 2 of 6
Does member require an Interpreter? Yes No If yes, what language : ___________________________________________________________________________
Is Care Coordination requested: Yes No (If yes, please explain):___________________________________________________________________________________
QUEST only: Potential SMI/SPMI/SEBD: Yes No
CLINICAL INFORMATION: (Please complete the following)
1. Please explain why member continues to require this Level of Care:______________________________________________________________________________
_____________________________________________________________________________________________________________________________________
2. Did member attend all scheduled sessions? Yes No If No, please list dates and reasons for non-‐attendance:______________________________________
_____________________________________________________________________________________________________________________________________
3. Date of most recent UA:___________________________________Results:________________________________________________________________________
If UA was not done, please explain why:____________________________________________________________________________________________________
4. Is member on a Behavior Contract? Yes No If yes, please explain why and attach a copy:
____________________________________________________________________________________________________________________________________
5. Does member attend any sober support meetings? Yes No
If yes, how many meeting per week:_______________________________________________________________________________________________________
If No, what is your plan to assist member in connecting to a sober support system in the community? __________________________________________________
____________________________________________________________________________________________________________________________________
6. Does member have a sponsor? Yes No If yes, How many contacts per week?_______________________________________________________________
7. Is member working on the 12 Steps? Yes No If yes, What step is member on?______________________________________________________________
8. Does member have a Sober Support Phone Tree? Yes No
If yes, how many #’s collected?____________________________ How often used?_________________________________________________________________
9. What is member’s current assignment?_____________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
10. Is member able to give feedback w/o being hurtful? __________________________________________________________________________________________
11. Is member able to take feedback w/o taking offense?__________________________________________________________________________________________
12. Any Significant insight/connections made? Any Behavior Changes? Yes No If yes, please explain:_______________________________________________
13. Has member learned coping skills? What skills? Please explain:__________________________________________________________________________________
April 2016
Page 2 of 6
Does member require an Interpreter? Yes No If yes, what language : ___________________________________________________________________________
Is Care Coordination requested: Yes No (If yes, please explain):___________________________________________________________________________________
QUEST only: Potential SMI/SPMI/SEBD: Yes No
CLINICAL INFORMATION: (Please complete the following)
1. Please explain why member continues to require this Level of Care:______________________________________________________________________________
_____________________________________________________________________________________________________________________________________
2. Did member attend all scheduled sessions? Yes No If No, please list dates and reasons for non-‐attendance:______________________________________
_____________________________________________________________________________________________________________________________________
3. Date of most recent UA:___________________________________Results:________________________________________________________________________
If UA was not done, please explain why:____________________________________________________________________________________________________
4. Is member on a Behavior Contract? Yes No If yes, please explain why and attach a copy:
____________________________________________________________________________________________________________________________________
5. Does member attend any sober support meetings? Yes No
If yes, how many meeting per week:_______________________________________________________________________________________________________
If No, what is your plan to assist member in connecting to a sober support system in the community? __________________________________________________
____________________________________________________________________________________________________________________________________
6. Does member have a sponsor? Yes No If yes, How many contacts per week?_______________________________________________________________
7. Is member working on the 12 Steps? Yes No If yes, What step is member on?______________________________________________________________
8. Does member have a Sober Support Phone Tree? Yes No
If yes, how many #’s collected?____________________________ How often used?_________________________________________________________________
9. What is member’s current assignment?_____________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
10. Is member able to give feedback w/o being hurtful? __________________________________________________________________________________________
11. Is member able to take feedback w/o taking offense?__________________________________________________________________________________________
12. Any Significant insight/connections made? Any Behavior Changes? Yes No If yes, please explain:_______________________________________________
13. Has member learned coping skills? What skills? Please explain:__________________________________________________________________________________
April 2016
Page 2 of 6
Does member require an Interpreter? Yes No If yes, what language : ___________________________________________________________________________
Is Care Coordination requested: Yes No (If yes, please explain):___________________________________________________________________________________
QUEST only: Potential SMI/SPMI/SEBD: Yes No
CLINICAL INFORMATION: (Please complete the following)
1. Please explain why member continues to require this Level of Care:______________________________________________________________________________
_____________________________________________________________________________________________________________________________________
2. Did member attend all scheduled sessions? Yes No If No, please list dates and reasons for non-‐attendance:______________________________________
_____________________________________________________________________________________________________________________________________
3. Date of most recent UA:___________________________________Results:________________________________________________________________________
If UA was not done, please explain why:____________________________________________________________________________________________________
4. Is member on a Behavior Contract? Yes No If yes, please explain why and attach a copy:
____________________________________________________________________________________________________________________________________
5. Does member attend any sober support meetings? Yes No
If yes, how many meeting per week:_______________________________________________________________________________________________________
If No, what is your plan to assist member in connecting to a sober support system in the community? __________________________________________________
____________________________________________________________________________________________________________________________________
6. Does member have a sponsor? Yes No If yes, How many contacts per week?_______________________________________________________________
7. Is member working on the 12 Steps? Yes No If yes, What step is member on?______________________________________________________________
8. Does member have a Sober Support Phone Tree? Yes No
If yes, how many #’s collected?____________________________ How often used?_________________________________________________________________
9. What is member’s current assignment?_____________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
10. Is member able to give feedback w/o being hurtful? __________________________________________________________________________________________
11. Is member able to take feedback w/o taking offense?__________________________________________________________________________________________
12. Any Significant insight/connections made? Any Behavior Changes? Yes No If yes, please explain:_______________________________________________
13. Has member learned coping skills? What skills? Please explain:__________________________________________________________________________________
April 2016
Page 2 of 6
Does member require an Interpreter? Yes No If yes, what language : ___________________________________________________________________________
Is Care Coordination requested: Yes No (If yes, please explain):___________________________________________________________________________________
QUEST only: Potential SMI/SPMI/SEBD: Yes No
CLINICAL INFORMATION: (Please complete the following)
1. Please explain why member continues to require this Level of Care:______________________________________________________________________________
_____________________________________________________________________________________________________________________________________
2. Did member attend all scheduled sessions? Yes No If No, please list dates and reasons for non-‐attendance:______________________________________
_____________________________________________________________________________________________________________________________________
3. Date of most recent UA:___________________________________Results:________________________________________________________________________
If UA was not done, please explain why:____________________________________________________________________________________________________
4. Is member on a Behavior Contract? Yes No If yes, please explain why and attach a copy:
____________________________________________________________________________________________________________________________________
5. Does member attend any sober support meetings? Yes No
If yes, how many meeting per week:_______________________________________________________________________________________________________
If No, what is your plan to assist member in connecting to a sober support system in the community? __________________________________________________
____________________________________________________________________________________________________________________________________
6. Does member have a sponsor? Yes No If yes, How many contacts per week?_______________________________________________________________
7. Is member working on the 12 Steps? Yes No If yes, What step is member on?______________________________________________________________
8. Does member have a Sober Support Phone Tree? Yes No
If yes, how many #’s collected?____________________________ How often used?_________________________________________________________________
9. What is member’s current assignment?_____________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
10. Is member able to give feedback w/o being hurtful? __________________________________________________________________________________________
11. Is member able to take feedback w/o taking offense?__________________________________________________________________________________________
12. Any Significant insight/connections made? Any Behavior Changes? Yes No If yes, please explain:_______________________________________________
13. Has member learned coping skills? What skills? Please explain:__________________________________________________________________________________
April 2016
Page 2 of 6
Does member require an Interpreter? Yes No If yes, what language : ___________________________________________________________________________
Is Care Coordination requested: Yes No (If yes, please explain):___________________________________________________________________________________
QUEST only: Potential SMI/SPMI/SEBD: Yes No
CLINICAL INFORMATION: (Please complete the following)
1. Please explain why member continues to require this Level of Care:______________________________________________________________________________
_____________________________________________________________________________________________________________________________________
2. Did member attend all scheduled sessions? Yes No If No, please list dates and reasons for non-‐attendance:______________________________________
_____________________________________________________________________________________________________________________________________
3. Date of most recent UA:___________________________________Results:________________________________________________________________________
If UA was not done, please explain why:____________________________________________________________________________________________________
4. Is member on a Behavior Contract? Yes No If yes, please explain why and attach a copy:
____________________________________________________________________________________________________________________________________
5. Does member attend any sober support meetings? Yes No
If yes, how many meeting per week:_______________________________________________________________________________________________________
If No, what is your plan to assist member in connecting to a sober support system in the community? __________________________________________________
____________________________________________________________________________________________________________________________________
6. Does member have a sponsor? Yes No If yes, How many contacts per week?_______________________________________________________________
7. Is member working on the 12 Steps? Yes No If yes, What step is member on?______________________________________________________________
8. Does member have a Sober Support Phone Tree? Yes No
If yes, how many #’s collected?____________________________ How often used?_________________________________________________________________
9. What is member’s current assignment?_____________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
10. Is member able to give feedback w/o being hurtful? __________________________________________________________________________________________
11. Is member able to take feedback w/o taking offense?__________________________________________________________________________________________
12. Any Significant insight/connections made? Any Behavior Changes? Yes No If yes, please explain:_______________________________________________
13. Has member learned coping skills? What skills? Please explain:__________________________________________________________________________________
April 2016
Page 2 of 6
Does member require an Interpreter? Yes No If yes, what language : ___________________________________________________________________________
Is Care Coordination requested: Yes No (If yes, please explain):___________________________________________________________________________________
QUEST only: Potential SMI/SPMI/SEBD: Yes No
CLINICAL INFORMATION: (Please complete the following)
1. Please explain why member continues to require this Level of Care:______________________________________________________________________________
_____________________________________________________________________________________________________________________________________
2. Did member attend all scheduled sessions? Yes No If No, please list dates and reasons for non-‐attendance:______________________________________
_____________________________________________________________________________________________________________________________________
3. Date of most recent UA:___________________________________Results:________________________________________________________________________
If UA was not done, please explain why:____________________________________________________________________________________________________
4. Is member on a Behavior Contract? Yes No If yes, please explain why and attach a copy:
____________________________________________________________________________________________________________________________________
5. Does member attend any sober support meetings? Yes No
If yes, how many meeting per week:_______________________________________________________________________________________________________
If No, what is your plan to assist member in connecting to a sober support system in the community? __________________________________________________
____________________________________________________________________________________________________________________________________
6. Does member have a sponsor? Yes No If yes, How many contacts per week?_______________________________________________________________
7. Is member working on the 12 Steps? Yes No If yes, What step is member on?______________________________________________________________
8. Does member have a Sober Support Phone Tree? Yes No
If yes, how many #’s collected?____________________________ How often used?_________________________________________________________________
9. What is member’s current assignment?_____________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
10. Is member able to give feedback w/o being hurtful? __________________________________________________________________________________________
11. Is member able to take feedback w/o taking offense?__________________________________________________________________________________________
12. Any Significant insight/connections made? Any Behavior Changes? Yes No If yes, please explain:_______________________________________________
13. Has member learned coping skills? What skills? Please explain:__________________________________________________________________________________
April 2016
Page 2 of 6
Does member require an Interpreter? Yes No If yes, what language : ___________________________________________________________________________
Is Care Coordination requested: Yes No (If yes, please explain):___________________________________________________________________________________
QUEST only: Potential SMI/SPMI/SEBD: Yes No
CLINICAL INFORMATION: (Please complete the following)
1. Please explain why member continues to require this Level of Care:______________________________________________________________________________
_____________________________________________________________________________________________________________________________________
2. Did member attend all scheduled sessions? Yes No If No, please list dates and reasons for non-‐attendance:______________________________________
_____________________________________________________________________________________________________________________________________
3. Date of most recent UA:___________________________________Results:________________________________________________________________________
If UA was not done, please explain why:____________________________________________________________________________________________________
4. Is member on a Behavior Contract? Yes No If yes, please explain why and attach a copy:
____________________________________________________________________________________________________________________________________
5. Does member attend any sober support meetings? Yes No
If yes, how many meeting per week:_______________________________________________________________________________________________________
If No, what is your plan to assist member in connecting to a sober support system in the community? __________________________________________________
____________________________________________________________________________________________________________________________________
6. Does member have a sponsor? Yes No If yes, How many contacts per week?_______________________________________________________________
7. Is member working on the 12 Steps? Yes No If yes, What step is member on?______________________________________________________________
8. Does member have a Sober Support Phone Tree? Yes No
If yes, how many #’s collected?____________________________ How often used?_________________________________________________________________
9. What is member’s current assignment?_____________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
10. Is member able to give feedback w/o being hurtful? __________________________________________________________________________________________
11. Is member able to take feedback w/o taking offense?__________________________________________________________________________________________
12. Any Significant insight/connections made? Any Behavior Changes? Yes No If yes, please explain:_______________________________________________
13. Has member learned coping skills? What skills? Please explain:__________________________________________________________________________________
April 2016
Page 2 of 6
Does member require an Interpreter? Yes No If yes, what language : ___________________________________________________________________________
Is Care Coordination requested: Yes No (If yes, please explain):___________________________________________________________________________________
QUEST only: Potential SMI/SPMI/SEBD: Yes No
CLINICAL INFORMATION: (Please complete the following)
1. Please explain why member continues to require this Level of Care:______________________________________________________________________________
_____________________________________________________________________________________________________________________________________
2. Did member attend all scheduled sessions? Yes No If No, please list dates and reasons for non-‐attendance:______________________________________
_____________________________________________________________________________________________________________________________________
3. Date of most recent UA:___________________________________Results:________________________________________________________________________
If UA was not done, please explain why:____________________________________________________________________________________________________
4. Is member on a Behavior Contract? Yes No If yes, please explain why and attach a copy:
____________________________________________________________________________________________________________________________________
5. Does member attend any sober support meetings? Yes No
If yes, how many meeting per week:_______________________________________________________________________________________________________
If No, what is your plan to assist member in connecting to a sober support system in the community? __________________________________________________
____________________________________________________________________________________________________________________________________
6. Does member have a sponsor? Yes No If yes, How many contacts per week?_______________________________________________________________
7. Is member working on the 12 Steps? Yes No If yes, What step is member on?______________________________________________________________
8. Does member have a Sober Support Phone Tree? Yes No
If yes, how many #’s collected?____________________________ How often used?_________________________________________________________________
9. What is member’s current assignment?_____________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
10. Is member able to give feedback w/o being hurtful? __________________________________________________________________________________________
11. Is member able to take feedback w/o taking offense?__________________________________________________________________________________________
12. Any Significant insight/connections made? Any Behavior Changes? Yes No If yes, please explain:_______________________________________________
13. Has member learned coping skills? What skills? Please explain:__________________________________________________________________________________
April 2016
Page 2 of 6
Does member require an Interpreter? Yes No If yes, what language : ___________________________________________________________________________
Is Care Coordination requested: Yes No (If yes, please explain):___________________________________________________________________________________
QUEST only: Potential SMI/SPMI/SEBD: Yes No
CLINICAL INFORMATION: (Please complete the following)
1. Please explain why member continues to require this Level of Care:______________________________________________________________________________
_____________________________________________________________________________________________________________________________________
2. Did member attend all scheduled sessions? Yes No If No, please list dates and reasons for non-‐attendance:______________________________________
_____________________________________________________________________________________________________________________________________
3. Date of most recent UA:___________________________________Results:________________________________________________________________________
If UA was not done, please explain why:____________________________________________________________________________________________________
4. Is member on a Behavior Contract? Yes No If yes, please explain why and attach a copy:
____________________________________________________________________________________________________________________________________
5. Does member attend any sober support meetings? Yes No
If yes, how many meeting per week:_______________________________________________________________________________________________________
If No, what is your plan to assist member in connecting to a sober support system in the community? __________________________________________________
____________________________________________________________________________________________________________________________________
6. Does member have a sponsor? Yes No If yes, How many contacts per week?_______________________________________________________________
7. Is member working on the 12 Steps? Yes No If yes, What step is member on?______________________________________________________________
8. Does member have a Sober Support Phone Tree? Yes No
If yes, how many #’s collected?____________________________ How often used?_________________________________________________________________
9. What is member’s current assignment?_____________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
10. Is member able to give feedback w/o being hurtful? __________________________________________________________________________________________
11. Is member able to take feedback w/o taking offense?__________________________________________________________________________________________
12. Any Significant insight/connections made? Any Behavior Changes? Yes No If yes, please explain:_______________________________________________
13. Has member learned coping skills? What skills? Please explain:__________________________________________________________________________________
April 2016
Page 2 of 6
Does member require an Interpreter? Yes No If yes, what language : ___________________________________________________________________________
Is Care Coordination requested: Yes No (If yes, please explain):___________________________________________________________________________________
QUEST only: Potential SMI/SPMI/SEBD: Yes No
CLINICAL INFORMATION: (Please complete the following)
1. Please explain why member continues to require this Level of Care:______________________________________________________________________________
_____________________________________________________________________________________________________________________________________
2. Did member attend all scheduled sessions? Yes No If No, please list dates and reasons for non-‐attendance:______________________________________
_____________________________________________________________________________________________________________________________________
3. Date of most recent UA:___________________________________Results:________________________________________________________________________
If UA was not done, please explain why:____________________________________________________________________________________________________
4. Is member on a Behavior Contract? Yes No If yes, please explain why and attach a copy:
____________________________________________________________________________________________________________________________________
5. Does member attend any sober support meetings? Yes No
If yes, how many meeting per week:_______________________________________________________________________________________________________
If No, what is your plan to assist member in connecting to a sober support system in the community? __________________________________________________
____________________________________________________________________________________________________________________________________
6. Does member have a sponsor? Yes No If yes, How many contacts per week?_______________________________________________________________
7. Is member working on the 12 Steps? Yes No If yes, What step is member on?______________________________________________________________
8. Does member have a Sober Support Phone Tree? Yes No
If yes, how many #’s collected?____________________________ How often used?_________________________________________________________________
9. What is member’s current assignment?_____________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
10. Is member able to give feedback w/o being hurtful? __________________________________________________________________________________________
11. Is member able to take feedback w/o taking offense?__________________________________________________________________________________________
12. Any Significant insight/connections made? Any Behavior Changes? Yes No If yes, please explain:_______________________________________________
13. Has member learned coping skills? What skills? Please explain:__________________________________________________________________________________
April 2016
Page 2 of 6
Does member require an Interpreter? Yes No If yes, what language : ___________________________________________________________________________
Is Care Coordination requested: Yes No (If yes, please explain):___________________________________________________________________________________
QUEST only: Potential SMI/SPMI/SEBD: Yes No
CLINICAL INFORMATION: (Please complete the following)
1. Please explain why member continues to require this Level of Care:______________________________________________________________________________
_____________________________________________________________________________________________________________________________________
2. Did member attend all scheduled sessions? Yes No If No, please list dates and reasons for non-‐attendance:______________________________________
_____________________________________________________________________________________________________________________________________
3. Date of most recent UA:___________________________________Results:________________________________________________________________________
If UA was not done, please explain why:____________________________________________________________________________________________________
4. Is member on a Behavior Contract? Yes No If yes, please explain why and attach a copy:
____________________________________________________________________________________________________________________________________
5. Does member attend any sober support meetings? Yes No
If yes, how many meeting per week:_______________________________________________________________________________________________________
If No, what is your plan to assist member in connecting to a sober support system in the community? __________________________________________________
____________________________________________________________________________________________________________________________________
6. Does member have a sponsor? Yes No If yes, How many contacts per week?_______________________________________________________________
7. Is member working on the 12 Steps? Yes No If yes, What step is member on?______________________________________________________________
8. Does member have a Sober Support Phone Tree? Yes No
If yes, how many #’s collected?____________________________ How often used?_________________________________________________________________
9. What is member’s current assignment?_____________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
10. Is member able to give feedback w/o being hurtful? __________________________________________________________________________________________
11. Is member able to take feedback w/o taking offense?__________________________________________________________________________________________
12. Any Significant insight/connections made? Any Behavior Changes? Yes No If yes, please explain:_______________________________________________
13. Has member learned coping skills? What skills? Please explain:__________________________________________________________________________________
April 2016
Page 2 of 6
Does member require an Interpreter? Yes No If yes, what language : ___________________________________________________________________________
Is Care Coordination requested: Yes No (If yes, please explain):___________________________________________________________________________________
QUEST only: Potential SMI/SPMI/SEBD: Yes No
CLINICAL INFORMATION: (Please complete the following)
1. Please explain why member continues to require this Level of Care:______________________________________________________________________________
_____________________________________________________________________________________________________________________________________
2. Did member attend all scheduled sessions? Yes No If No, please list dates and reasons for non-‐attendance:______________________________________
_____________________________________________________________________________________________________________________________________
3. Date of most recent UA:___________________________________Results:________________________________________________________________________
If UA was not done, please explain why:____________________________________________________________________________________________________
4. Is member on a Behavior Contract? Yes No If yes, please explain why and attach a copy:
____________________________________________________________________________________________________________________________________
5. Does member attend any sober support meetings? Yes No
If yes, how many meeting per week:_______________________________________________________________________________________________________
If No, what is your plan to assist member in connecting to a sober support system in the community? __________________________________________________
____________________________________________________________________________________________________________________________________
6. Does member have a sponsor? Yes No If yes, How many contacts per week?_______________________________________________________________
7. Is member working on the 12 Steps? Yes No If yes, What step is member on?______________________________________________________________
8. Does member have a Sober Support Phone Tree? Yes No
If yes, how many #’s collected?____________________________ How often used?_________________________________________________________________
9. What is member’s current assignment?_____________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
10. Is member able to give feedback w/o being hurtful? __________________________________________________________________________________________
11. Is member able to take feedback w/o taking offense?__________________________________________________________________________________________
12. Any Significant insight/connections made? Any Behavior Changes? Yes No If yes, please explain:_______________________________________________
13. Has member learned coping skills? What skills? Please explain:__________________________________________________________________________________
April 2016
Page 2 of 6
Does member require an Interpreter? Yes No If yes, what language : ___________________________________________________________________________
Is Care Coordination requested: Yes No (If yes, please explain):___________________________________________________________________________________
QUEST only: Potential SMI/SPMI/SEBD: Yes No
CLINICAL INFORMATION: (Please complete the following)
1. Please explain why member continues to require this Level of Care:______________________________________________________________________________
_____________________________________________________________________________________________________________________________________
2. Did member attend all scheduled sessions? Yes No If No, please list dates and reasons for non-‐attendance:______________________________________
_____________________________________________________________________________________________________________________________________
3. Date of most recent UA:___________________________________Results:________________________________________________________________________
If UA was not done, please explain why:____________________________________________________________________________________________________
4. Is member on a Behavior Contract? Yes No If yes, please explain why and attach a copy:
____________________________________________________________________________________________________________________________________
5. Does member attend any sober support meetings? Yes No
If yes, how many meeting per week:_______________________________________________________________________________________________________
If No, what is your plan to assist member in connecting to a sober support system in the community? __________________________________________________
____________________________________________________________________________________________________________________________________
6. Does member have a sponsor? Yes No If yes, How many contacts per week?_______________________________________________________________
7. Is member working on the 12 Steps? Yes No If yes, What step is member on?______________________________________________________________
8. Does member have a Sober Support Phone Tree? Yes No
If yes, how many #’s collected?____________________________ How often used?_________________________________________________________________
9. What is member’s current assignment?_____________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
10. Is member able to give feedback w/o being hurtful? __________________________________________________________________________________________
11. Is member able to take feedback w/o taking offense?__________________________________________________________________________________________
12. Any Significant insight/connections made? Any Behavior Changes? Yes No If yes, please explain:_______________________________________________
13. Has member learned coping skills? What skills? Please explain:__________________________________________________________________________________
April 2016
Page 2 of 6
Does member require an Interpreter? Yes No If yes, what language : ___________________________________________________________________________
Is Care Coordination requested: Yes No (If yes, please explain):___________________________________________________________________________________
QUEST only: Potential SMI/SPMI/SEBD: Yes No
CLINICAL INFORMATION: (Please complete the following)
1. Please explain why member continues to require this Level of Care:______________________________________________________________________________
_____________________________________________________________________________________________________________________________________
2. Did member attend all scheduled sessions? Yes No If No, please list dates and reasons for non-‐attendance:______________________________________
_____________________________________________________________________________________________________________________________________
3. Date of most recent UA:___________________________________Results:________________________________________________________________________
If UA was not done, please explain why:____________________________________________________________________________________________________
4. Is member on a Behavior Contract? Yes No If yes, please explain why and attach a copy:
____________________________________________________________________________________________________________________________________
5. Does member attend any sober support meetings? Yes No
If yes, how many meeting per week:_______________________________________________________________________________________________________
If No, what is your plan to assist member in connecting to a sober support system in the community? __________________________________________________
____________________________________________________________________________________________________________________________________
6. Does member have a sponsor? Yes No If yes, How many contacts per week?_______________________________________________________________
7. Is member working on the 12 Steps? Yes No If yes, What step is member on?______________________________________________________________
8. Does member have a Sober Support Phone Tree? Yes No
If yes, how many #’s collected?____________________________ How often used?_________________________________________________________________
9. What is member’s current assignment?_____________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
10. Is member able to give feedback w/o being hurtful? __________________________________________________________________________________________
11. Is member able to take feedback w/o taking offense?__________________________________________________________________________________________
12. Any Significant insight/connections made? Any Behavior Changes? Yes No If yes, please explain:_______________________________________________
13. Has member learned coping skills? What skills? Please explain:__________________________________________________________________________________
April 2016
April 2016 Page 3 of 8
Page 2 of 6
Does member require an Interpreter? Yes No If yes, what language : ___________________________________________________________________________
Is Care Coordination requested: Yes No (If yes, please explain):___________________________________________________________________________________
QUEST only: Potential SMI/SPMI/SEBD: Yes No
CLINICAL INFORMATION: (Please complete the following)
1. Please explain why member continues to require this Level of Care:______________________________________________________________________________
_____________________________________________________________________________________________________________________________________
2. Did member attend all scheduled sessions? Yes No If No, please list dates and reasons for non-‐attendance:______________________________________
_____________________________________________________________________________________________________________________________________
3. Date of most recent UA:___________________________________Results:________________________________________________________________________
If UA was not done, please explain why:____________________________________________________________________________________________________
4. Is member on a Behavior Contract? Yes No If yes, please explain why and attach a copy:
____________________________________________________________________________________________________________________________________
5. Does member attend any sober support meetings? Yes No
If yes, how many meeting per week:_______________________________________________________________________________________________________
If No, what is your plan to assist member in connecting to a sober support system in the community? __________________________________________________
____________________________________________________________________________________________________________________________________
6. Does member have a sponsor? Yes No If yes, How many contacts per week?_______________________________________________________________
7. Is member working on the 12 Steps? Yes No If yes, What step is member on?______________________________________________________________
8. Does member have a Sober Support Phone Tree? Yes No
If yes, how many #’s collected?____________________________ How often used?_________________________________________________________________
9. What is member’s current assignment?_____________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
10. Is member able to give feedback w/o being hurtful? __________________________________________________________________________________________
11. Is member able to take feedback w/o taking offense?__________________________________________________________________________________________
12. Any Significant insight/connections made? Any Behavior Changes? Yes No If yes, please explain:_______________________________________________
13. Has member learned coping skills? What skills? Please explain:__________________________________________________________________________________
April 2016
Page 2 of 6
Does member require an Interpreter? Yes No If yes, what language : ___________________________________________________________________________
Is Care Coordination requested: Yes No (If yes, please explain):___________________________________________________________________________________
QUEST only: Potential SMI/SPMI/SEBD: Yes No
CLINICAL INFORMATION: (Please complete the following)
1. Please explain why member continues to require this Level of Care:______________________________________________________________________________
_____________________________________________________________________________________________________________________________________
2. Did member attend all scheduled sessions? Yes No If No, please list dates and reasons for non-‐attendance:______________________________________
_____________________________________________________________________________________________________________________________________
3. Date of most recent UA:___________________________________Results:________________________________________________________________________
If UA was not done, please explain why:____________________________________________________________________________________________________
4. Is member on a Behavior Contract? Yes No If yes, please explain why and attach a copy:
____________________________________________________________________________________________________________________________________
5. Does member attend any sober support meetings? Yes No
If yes, how many meeting per week:_______________________________________________________________________________________________________
If No, what is your plan to assist member in connecting to a sober support system in the community? __________________________________________________
____________________________________________________________________________________________________________________________________
6. Does member have a sponsor? Yes No If yes, How many contacts per week?_______________________________________________________________
7. Is member working on the 12 Steps? Yes No If yes, What step is member on?______________________________________________________________
8. Does member have a Sober Support Phone Tree? Yes No
If yes, how many #’s collected?____________________________ How often used?_________________________________________________________________
9. What is member’s current assignment?_____________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
10. Is member able to give feedback w/o being hurtful? __________________________________________________________________________________________
11. Is member able to take feedback w/o taking offense?__________________________________________________________________________________________
12. Any Significant insight/connections made? Any Behavior Changes? Yes No If yes, please explain:_______________________________________________
13. Has member learned coping skills? What skills? Please explain:__________________________________________________________________________________
April 2016
Page 2 of 6
Does member require an Interpreter? Yes No If yes, what language : ___________________________________________________________________________
Is Care Coordination requested: Yes No (If yes, please explain):___________________________________________________________________________________
QUEST only: Potential SMI/SPMI/SEBD: Yes No
CLINICAL INFORMATION: (Please complete the following)
1. Please explain why member continues to require this Level of Care:______________________________________________________________________________
_____________________________________________________________________________________________________________________________________
2. Did member attend all scheduled sessions? Yes No If No, please list dates and reasons for non-‐attendance:______________________________________
_____________________________________________________________________________________________________________________________________
3. Date of most recent UA:___________________________________Results:________________________________________________________________________
If UA was not done, please explain why:____________________________________________________________________________________________________
4. Is member on a Behavior Contract? Yes No If yes, please explain why and attach a copy:
____________________________________________________________________________________________________________________________________
5. Does member attend any sober support meetings? Yes No
If yes, how many meeting per week:_______________________________________________________________________________________________________
If No, what is your plan to assist member in connecting to a sober support system in the community? __________________________________________________
____________________________________________________________________________________________________________________________________
6. Does member have a sponsor? Yes No If yes, How many contacts per week?_______________________________________________________________
7. Is member working on the 12 Steps? Yes No If yes, What step is member on?______________________________________________________________
8. Does member have a Sober Support Phone Tree? Yes No
If yes, how many #’s collected?____________________________ How often used?_________________________________________________________________
9. What is member’s current assignment?_____________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
10. Is member able to give feedback w/o being hurtful? __________________________________________________________________________________________
11. Is member able to take feedback w/o taking offense?__________________________________________________________________________________________
12. Any Significant insight/connections made? Any Behavior Changes? Yes No If yes, please explain:_______________________________________________
13. Has member learned coping skills? What skills? Please explain:__________________________________________________________________________________
April 2016
Page 2 of 6
Does member require an Interpreter? Yes No If yes, what language : ___________________________________________________________________________
Is Care Coordination requested: Yes No (If yes, please explain):___________________________________________________________________________________
QUEST only: Potential SMI/SPMI/SEBD: Yes No
CLINICAL INFORMATION: (Please complete the following)
1. Please explain why member continues to require this Level of Care:______________________________________________________________________________
_____________________________________________________________________________________________________________________________________
2. Did member attend all scheduled sessions? Yes No If No, please list dates and reasons for non-‐attendance:______________________________________
_____________________________________________________________________________________________________________________________________
3. Date of most recent UA:___________________________________Results:________________________________________________________________________
If UA was not done, please explain why:____________________________________________________________________________________________________
4. Is member on a Behavior Contract? Yes No If yes, please explain why and attach a copy:
____________________________________________________________________________________________________________________________________
5. Does member attend any sober support meetings? Yes No
If yes, how many meeting per week:_______________________________________________________________________________________________________
If No, what is your plan to assist member in connecting to a sober support system in the community? __________________________________________________
____________________________________________________________________________________________________________________________________
6. Does member have a sponsor? Yes No If yes, How many contacts per week?_______________________________________________________________
7. Is member working on the 12 Steps? Yes No If yes, What step is member on?______________________________________________________________
8. Does member have a Sober Support Phone Tree? Yes No
If yes, how many #’s collected?____________________________ How often used?_________________________________________________________________
9. What is member’s current assignment?_____________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
10. Is member able to give feedback w/o being hurtful? __________________________________________________________________________________________
11. Is member able to take feedback w/o taking offense?__________________________________________________________________________________________
12. Any Significant insight/connections made? Any Behavior Changes? Yes No If yes, please explain:_______________________________________________
13. Has member learned coping skills? What skills? Please explain:__________________________________________________________________________________
April 2016
Page 2 of 6
Does member require an Interpreter? Yes No If yes, what language : ___________________________________________________________________________
Is Care Coordination requested: Yes No (If yes, please explain):___________________________________________________________________________________
QUEST only: Potential SMI/SPMI/SEBD: Yes No
CLINICAL INFORMATION: (Please complete the following)
1. Please explain why member continues to require this Level of Care:______________________________________________________________________________
_____________________________________________________________________________________________________________________________________
2. Did member attend all scheduled sessions? Yes No If No, please list dates and reasons for non-‐attendance:______________________________________
_____________________________________________________________________________________________________________________________________
3. Date of most recent UA:___________________________________Results:________________________________________________________________________
If UA was not done, please explain why:____________________________________________________________________________________________________
4. Is member on a Behavior Contract? Yes No If yes, please explain why and attach a copy:
____________________________________________________________________________________________________________________________________
5. Does member attend any sober support meetings? Yes No
If yes, how many meeting per week:_______________________________________________________________________________________________________
If No, what is your plan to assist member in connecting to a sober support system in the community? __________________________________________________
____________________________________________________________________________________________________________________________________
6. Does member have a sponsor? Yes No If yes, How many contacts per week?_______________________________________________________________
7. Is member working on the 12 Steps? Yes No If yes, What step is member on?______________________________________________________________
8. Does member have a Sober Support Phone Tree? Yes No
If yes, how many #’s collected?____________________________ How often used?_________________________________________________________________
9. What is member’s current assignment?_____________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
10. Is member able to give feedback w/o being hurtful? __________________________________________________________________________________________
11. Is member able to take feedback w/o taking offense?__________________________________________________________________________________________
12. Any Significant insight/connections made? Any Behavior Changes? Yes No If yes, please explain:_______________________________________________
13. Has member learned coping skills? What skills? Please explain:__________________________________________________________________________________
April 2016
Page 2 of 6
Does member require an Interpreter? Yes No If yes, what language : ___________________________________________________________________________
Is Care Coordination requested: Yes No (If yes, please explain):___________________________________________________________________________________
QUEST only: Potential SMI/SPMI/SEBD: Yes No
CLINICAL INFORMATION: (Please complete the following)
1. Please explain why member continues to require this Level of Care:______________________________________________________________________________
_____________________________________________________________________________________________________________________________________
2. Did member attend all scheduled sessions? Yes No If No, please list dates and reasons for non-‐attendance:______________________________________
_____________________________________________________________________________________________________________________________________
3. Date of most recent UA:___________________________________Results:________________________________________________________________________
If UA was not done, please explain why:____________________________________________________________________________________________________
4. Is member on a Behavior Contract? Yes No If yes, please explain why and attach a copy:
____________________________________________________________________________________________________________________________________
5. Does member attend any sober support meetings? Yes No
If yes, how many meeting per week:_______________________________________________________________________________________________________
If No, what is your plan to assist member in connecting to a sober support system in the community? __________________________________________________
____________________________________________________________________________________________________________________________________
6. Does member have a sponsor? Yes No If yes, How many contacts per week?_______________________________________________________________
7. Is member working on the 12 Steps? Yes No If yes, What step is member on?______________________________________________________________
8. Does member have a Sober Support Phone Tree? Yes No
If yes, how many #’s collected?____________________________ How often used?_________________________________________________________________
9. What is member’s current assignment?_____________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
11. Is member able to take feedback w/o taking offense?__________________________________________________________________________________________
12. Any Significant insight/connections made? Any Behavior Changes? Yes No If yes, please explain:_______________________________________________
13. Has member learned coping skills? What skills? Please explain:__________________________________________________________________________________
April 2016
Page 2 of 6
Does member require an Interpreter? Yes No If yes, what language : ___________________________________________________________________________
Is Care Coordination requested: Yes No (If yes, please explain):___________________________________________________________________________________
QUEST only: Potential SMI/SPMI/SEBD: Yes No
CLINICAL INFORMATION: (Please complete the following)
1. Please explain why member continues to require this Level of Care:______________________________________________________________________________
_____________________________________________________________________________________________________________________________________
2. Did member attend all scheduled sessions? Yes No If No, please list dates and reasons for non-‐attendance:______________________________________
_____________________________________________________________________________________________________________________________________
3. Date of most recent UA:___________________________________Results:________________________________________________________________________
If UA was not done, please explain why:____________________________________________________________________________________________________
4. Is member on a Behavior Contract? Yes No If yes, please explain why and attach a copy:
____________________________________________________________________________________________________________________________________
5. Does member attend any sober support meetings? Yes No
If yes, how many meeting per week:_______________________________________________________________________________________________________
If No, what is your plan to assist member in connecting to a sober support system in the community? __________________________________________________
____________________________________________________________________________________________________________________________________
6. Does member have a sponsor? Yes No If yes, How many contacts per week?_______________________________________________________________
7. Is member working on the 12 Steps? Yes No If yes, What step is member on?______________________________________________________________
8. Does member have a Sober Support Phone Tree? Yes No
If yes, how many #’s collected?____________________________ How often used?_________________________________________________________________
9. What is member’s current assignment?_____________________________________________________________________________________________________
11. Is member able to take feedback w/o taking offense?__________________________________________________________________________________________
12. Any Significant insight/connections made? Any Behavior Changes? Yes No If yes, please explain:_______________________________________________
13. Has member learned coping skills? What skills? Please explain:__________________________________________________________________________________
April 2016
Page 2 of 6
Does member require an Interpreter? Yes No If yes, what language : ___________________________________________________________________________
Is Care Coordination requested: Yes No (If yes, please explain):___________________________________________________________________________________
QUEST only: Potential SMI/SPMI/SEBD: Yes No
CLINICAL INFORMATION: (Please complete the following)
1. Please explain why member continues to require this Level of Care:______________________________________________________________________________
_____________________________________________________________________________________________________________________________________
2. Did member attend all scheduled sessions? Yes No If No, please list dates and reasons for non-‐attendance:______________________________________
_____________________________________________________________________________________________________________________________________
3. Date of most recent UA:___________________________________Results:________________________________________________________________________
If UA was not done, please explain why:____________________________________________________________________________________________________
4. Is member on a Behavior Contract? Yes No If yes, please explain why and attach a copy:
____________________________________________________________________________________________________________________________________
5. Does member attend any sober support meetings? Yes No
If yes, how many meeting per week:_______________________________________________________________________________________________________
If No, what is your plan to assist member in connecting to a sober support system in the community? __________________________________________________
____________________________________________________________________________________________________________________________________
6. Does member have a sponsor? Yes No If yes, How many contacts per week?_______________________________________________________________
7. Is member working on the 12 Steps? Yes No If yes, What step is member on?______________________________________________________________
8. Does member have a Sober Support Phone Tree? Yes No
If yes, how many #’s collected?____________________________ How often used?_________________________________________________________________
9. What is member’s current assignment?_____________________________________________________________________________________________________
11. Is member able to take feedback w/o taking offense?__________________________________________________________________________________________
12. Any Significant insight/connections made? Any Behavior Changes? Yes No If yes, please explain:_______________________________________________
13. Has member learned coping skills? What skills? Please explain:__________________________________________________________________________________
April 2016
Page 2 of 6
Does member require an Interpreter? Yes No If yes, what language : ___________________________________________________________________________
Is Care Coordination requested: Yes No (If yes, please explain):___________________________________________________________________________________
QUEST only: Potential SMI/SPMI/SEBD: Yes No
CLINICAL INFORMATION: (Please complete the following)
1. Please explain why member continues to require this Level of Care:______________________________________________________________________________
_____________________________________________________________________________________________________________________________________
2. Did member attend all scheduled sessions? Yes No If No, please list dates and reasons for non-‐attendance:______________________________________
_____________________________________________________________________________________________________________________________________
3. Date of most recent UA:___________________________________Results:________________________________________________________________________
If UA was not done, please explain why:____________________________________________________________________________________________________
4. Is member on a Behavior Contract? Yes No If yes, please explain why and attach a copy:
____________________________________________________________________________________________________________________________________
5. Does member attend any sober support meetings? Yes No
If yes, how many meeting per week:_______________________________________________________________________________________________________
If No, what is your plan to assist member in connecting to a sober support system in the community? __________________________________________________
____________________________________________________________________________________________________________________________________
6. Does member have a sponsor? Yes No If yes, How many contacts per week?_______________________________________________________________
7. Is member working on the 12 Steps? Yes No If yes, What step is member on?______________________________________________________________
8. Does member have a Sober Support Phone Tree? Yes No
If yes, how many #’s collected?____________________________ How often used?_________________________________________________________________
9. What is member’s current assignment?_____________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
10. Is member able to give feedback w/o being hurtful? __________________________________________________________________________________________
11. Is member able to take feedback w/o taking offense?__________________________________________________________________________________________
12. Any Significant insight/connections made? Any Behavior Changes? Yes No If yes, please explain:_______________________________________________
13. Has member learned coping skills? What skills? Please explain:__________________________________________________________________________________
April 2016
April 2016 Page 4 of 8
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Page 3 of 3
ASAM DIMENSIONS (please explain all medium and high ratings) 1. Alcohol Intox. And/or Withdrawal Potential
• Any risk of severe withdrawal/seizures?• Any current signs of withdrawal?
LOW MED HIGH EXPLAIN
2. Biomedical Conditions & Complications• Any current physical illness (besides withdrawal) that may
impact course of treatment?• Is member pregnant? Yes No
3. Emotional/ Behavioral or Cognitive Conditions & Complications• Any psych. Illness or psychological, behavioral, or emotional
problems that may impact the course of treatment?4. Readiness to Change (Treatment Acceptance/Resistance)
• Is the member objecting/resistant to treatment?• What is the member’s readiness to change?
5. Relapse (Continued Use Potential)• Is the member in immediate danger of continued severe
distress, and drinking/drug behavior?• Does the member have any understanding of, or skills in
which to cope with his/her addiction problems in order toprevent relapse/continued use?
6. Recovery Environment• Are there family members, significant others, living
situations, or school/work situations that pose a threat to TXengagement and success?
• Does the member have supportive friendships, financial,educational, or vocational resources that will increase thelikelihood of successful TX?
Provider Signature: ______________________________________Date:_______________________
LEVEL OF CARE DETERMINATION: **For AC Use onlyLOC DATE OF
REQUESTSESSIONS START DATE END DATE TX PLAN
DUE DATETCDUE DATE
AUTH # CRITERIA USED
APPROVED: YES NO PARTIAL DATE OF DECISION: Reviewers signature____________________________ MD Signature:__________________________________
1357 Kapiolani Blvd., Ste. 1250, Honolulu, HI 96814. BH Phone: 973-‐2475 (Oahu) or 1-‐888-‐875-‐4979 (NI). BH FAX: 973-‐6324 or 1-‐800-‐293-‐4580
April 2016 Page 3 of 3
1357 Kapiolani Blvd., Ste. 1250, Honolulu, HI 96814. To contact the BH Dept., call 973-1650 (Oahu) or 1-800-434-1002 (NI). BH FAX: 973 -6324 or 1-800-293-4580
EXPLAIN
Page 3 of 3
ASAM DIMENSIONS (please explain all medium and high ratings)1. Alcohol Intox. And/or Withdrawal Potential
• Any risk of severe withdrawal/seizures?• Any current signs of withdrawal?
LOW MED HIGH EXPLAIN
2. Biomedical Conditions & Complications• Any current physical illness (besides withdrawal) that may
impact course of treatment?• Is member pregnant? Yes No
3. Emotional/ Behavioral or Cognitive Conditions & Complications• Any psych. Illness or psychological, behavioral, or emotional
problems that may impact the course of treatment?4. Readiness to Change (Treatment Acceptance/Resistance)
• Is the member objecting/resistant to treatment?• What is the member’s readiness to change?
5. Relapse (Continued Use Potential)• Is the member in immediate danger of continued severe
distress, and drinking/drug behavior?• Does the member have any understanding of, or skills in
which to cope with his/her addiction problems in order toprevent relapse/continued use?
6. Recovery Environment• Are there family members, significant others, living
situations, or school/work situations that pose a threat to TXengagement and success?
• Does the member have supportive friendships, financial,educational, or vocational resources that will increase thelikelihood of successful TX?
Provider Signature: ______________________________________Date:_______________________
LEVEL OF CARE DETERMINATION: **For AC Use onlyLOC DATE OF
REQUESTSESSIONS START DATE END DATE TX PLAN
DUE DATETCDUE DATE
AUTH # CRITERIA USED
APPROVED: YES NO PARTIAL DATE OF DECISION: Reviewers signature____________________________ MD Signature:__________________________________
1357 Kapiolani Blvd., Ste. 1250, Honolulu, HI 96814. BH Phone: 973-‐2475 (Oahu) or 1-‐888-‐875-‐4979 (NI). BH FAX: 973-‐6324 or 1-‐800-‐293-‐4580
April 2016 Page 3 of 3
1357 Kapiolani Blvd., Ste. 1250, Honolulu, HI 96814. To contact the BH Dept., call 973-1650 (Oahu) or 1-800-434-1002 (NI). BH FAX: 973 -6324 or 1- 800- 293-4580
April 2016 Page 5 of 8
• Any current physical illness (besides withdrawal) that may impact course of treatment?• Is member pregnant?
2. Biomedical Conditions & Complications HIGHLOW MED
Yes No
• Any risk of severe withdrawal/seizures?• Any current signs of withdrawal?
EXPLAIN
1. Alcohol Intox. And/or Withdrawal Potential HIGHLOW MED
Page 3 of 3
ASAM DIMENSIONS (please explain all medium and high ratings) 1. Alcohol Intox. And/or Withdrawal Potential
• Any risk of severe withdrawal/seizures?• Any current signs of withdrawal?
LOW MED HIGH EXPLAIN
2. Biomedical Conditions & Complications• Any current physical illness (besides withdrawal) that may
impact course of treatment?• Is member pregnant? Yes No
3. Emotional/ Behavioral or Cognitive Conditions & Complications• Any psych. Illness or psychological, behavioral, or emotional
problems that may impact the course of treatment?4. Readiness to Change (Treatment Acceptance/Resistance)
• Is the member objecting/resistant to treatment?• What is the member’s readiness to change?
5. Relapse (Continued Use Potential)• Is the member in immediate danger of continued severe
distress, and drinking/drug behavior?• Does the member have any understanding of, or skills in
which to cope with his/her addiction problems in order toprevent relapse/continued use?
6. Recovery Environment• Are there family members, significant others, living
situations, or school/work situations that pose a threat to TXengagement and success?
• Does the member have supportive friendships, financial,educational, or vocational resources that will increase thelikelihood of successful TX?
Provider Signature: ______________________________________Date:_______________________
LEVEL OF CARE DETERMINATION: **For AC Use onlyLOC DATE OF
REQUESTSESSIONS START DATE END DATE TX PLAN
DUE DATETCDUE DATE
AUTH # CRITERIA USED
APPROVED: YES NO PARTIAL DATE OF DECISION: Reviewers signature____________________________ MD Signature:__________________________________
1357 Kapiolani Blvd., Ste. 1250, Honolulu, HI 96814. BH Phone: 973-‐2475 (Oahu) or 1-‐888-‐875-‐4979 (NI). BH FAX: 973-‐6324 or 1-‐800-‐293-‐4580
April 2016 Page 3 of 3
1357 Kapiolani Blvd., Ste. 1250, Honolulu, HI 96814. To contact the BH Dept., call 973-1650 (Oahu) or 1-800-434-1002 (NI). BH FAX: 973 -6324 or 1-800-293-4580
EXPLAIN
EXPLAIN
Page 3 of 3
ASAM DIMENSIONS (please explain all medium and high ratings)1. Alcohol Intox. And/or Withdrawal Potential
• Any risk of severe withdrawal/seizures?• Any current signs of withdrawal?
LOW MED HIGH EXPLAIN
2. Biomedical Conditions & Complications• Any current physical illness (besides withdrawal) that may
impact course of treatment?• Is member pregnant? Yes No
3. Emotional/ Behavioral or Cognitive Conditions & Complications• Any psych. Illness or psychological, behavioral, or emotional
problems that may impact the course of treatment?4. Readiness to Change (Treatment Acceptance/Resistance)
• Is the member objecting/resistant to treatment?• What is the member’s readiness to change?
5. Relapse (Continued Use Potential)• Is the member in immediate danger of continued severe
distress, and drinking/drug behavior?• Does the member have any understanding of, or skills in
which to cope with his/her addiction problems in order toprevent relapse/continued use?
6. Recovery Environment• Are there family members, significant others, living
situations, or school/work situations that pose a threat to TXengagement and success?
• Does the member have supportive friendships, financial,educational, or vocational resources that will increase thelikelihood of successful TX?
Provider Signature: ______________________________________Date:_______________________
LEVEL OF CARE DETERMINATION: **For AC Use onlyLOC DATE OF
REQUESTSESSIONS START DATE END DATE TX PLAN
DUE DATETCDUE DATE
AUTH # CRITERIA USED
APPROVED: YES NO PARTIAL DATE OF DECISION: Reviewers signature____________________________ MD Signature:__________________________________
1357 Kapiolani Blvd., Ste. 1250, Honolulu, HI 96814. BH Phone: 973-‐2475 (Oahu) or 1-‐888-‐875-‐4979 (NI). BH FAX: 973-‐6324 or 1-‐800-‐293-‐4580
April 2016 Page 3 of 3
1357 Kapiolani Blvd., Ste. 1250, Honolulu, HI 96814. To contact the BH Dept., call 973-1650 (Oahu) or 1-800-434-1002 (NI). BH FAX: 973 -6324 or 1- 800- 293-4580
April 2016 Page 6 of 8
• Is the member objecting/resistant to treatment?• What is the member’s readiness to change?
4. Readiness to Change (Treatment Acceptance/Resistance) HIGHLOW MED
• Any psych. Illness or psychological, behavioral, or emotional problems that may impact the course of treatment?3. Emotional/ Behavioral or Cognitive Conditions & Complications HIGHLOW MED
Page 3 of 3
ASAM DIMENSIONS (please explain all medium and high ratings) 1. Alcohol Intox. And/or Withdrawal Potential
• Any risk of severe withdrawal/seizures?• Any current signs of withdrawal?
LOW MED HIGH EXPLAIN
2. Biomedical Conditions & Complications• Any current physical illness (besides withdrawal) that may
impact course of treatment?• Is member pregnant? Yes No
3. Emotional/ Behavioral or Cognitive Conditions & Complications• Any psych. Illness or psychological, behavioral, or emotional
problems that may impact the course of treatment?4. Readiness to Change (Treatment Acceptance/Resistance)
• Is the member objecting/resistant to treatment?• What is the member’s readiness to change?
5. Relapse (Continued Use Potential)• Is the member in immediate danger of continued severe
distress, and drinking/drug behavior?• Does the member have any understanding of, or skills in
which to cope with his/her addiction problems in order toprevent relapse/continued use?
6. Recovery Environment• Are there family members, significant others, living
situations, or school/work situations that pose a threat to TXengagement and success?
• Does the member have supportive friendships, financial,educational, or vocational resources that will increase thelikelihood of successful TX?
Provider Signature: ______________________________________Date:_______________________
LEVEL OF CARE DETERMINATION: **For AC Use onlyLOC DATE OF
REQUESTSESSIONS START DATE END DATE TX PLAN
DUE DATETCDUE DATE
AUTH # CRITERIA USED
APPROVED: YES NO PARTIAL DATE OF DECISION: Reviewers signature____________________________ MD Signature:__________________________________
1357 Kapiolani Blvd., Ste. 1250, Honolulu, HI 96814. BH Phone: 973-‐2475 (Oahu) or 1-‐888-‐875-‐4979 (NI). BH FAX: 973-‐6324 or 1-‐800-‐293-‐4580
April 2016 Page 3 of 3
1357 Kapiolani Blvd., Ste. 1250, Honolulu, HI 96814. To contact the BH Dept., call 973-1650 (Oahu) or 1-800-434-1002 (NI). BH FAX: 973 -6324 or 1-800-293-4580
EXPLAIN
EXPLAIN
Provider Signature: _____________________________Date:___________________
• Does the member have supportive friendships, financial, educational, or vocational resources that will increase the likelihood of successful TX?
• Are there family members, significant others, living situations, or school/work situations that pose a threat to TX engagement and success?
6. Recovery Environment HIGHLOW MED
• Is the member in immediate danger of continued severe distress, and drinking/drug behavior?
• Does the member have any understanding of, or skills in which to cope with his/her addiction problems in order to prevent relapse/continued use?
5. Relapse (Continued Use Potential) HIGHLOW MED
April 2016
Page 3 of 3
ASAM DIMENSIONS (please explain all medium and high ratings)1. Alcohol Intox. And/or Withdrawal Potential
• Any risk of severe withdrawal/seizures?• Any current signs of withdrawal?
LOW MED HIGH EXPLAIN
2. Biomedical Conditions & Complications• Any current physical illness (besides withdrawal) that may
impact course of treatment?• Is member pregnant? Yes No
3. Emotional/ Behavioral or Cognitive Conditions & Complications• Any psych. Illness or psychological, behavioral, or emotional
problems that may impact the course of treatment?4. Readiness to Change (Treatment Acceptance/Resistance)
• Is the member objecting/resistant to treatment?• What is the member’s readiness to change?
5. Relapse (Continued Use Potential)• Is the member in immediate danger of continued severe
distress, and drinking/drug behavior?• Does the member have any understanding of, or skills in
which to cope with his/her addiction problems in order toprevent relapse/continued use?
6. Recovery Environment• Are there family members, significant others, living
situations, or school/work situations that pose a threat to TXengagement and success?
• Does the member have supportive friendships, financial,educational, or vocational resources that will increase thelikelihood of successful TX?
Provider Signature: ______________________________________Date:_______________________
LEVEL OF CARE DETERMINATION: **For AC Use onlyLOC DATE OF
REQUESTSESSIONS START DATE END DATE TX PLAN
DUE DATETCDUE DATE
AUTH # CRITERIA USED
APPROVED: YES NO PARTIAL DATE OF DECISION: Reviewers signature____________________________ MD Signature:__________________________________
1357 Kapiolani Blvd., Ste. 1250, Honolulu, HI 96814. BH Phone: 973-‐2475 (Oahu) or 1-‐888-‐875-‐4979 (NI). BH FAX: 973-‐6324 or 1-‐800-‐293-‐4580
April 2016 Page 3 of 3
1357 Kapiolani Blvd., Ste. 1250, Honolulu, HI 96814. To contact the BH Dept., call 973-1650 (Oahu) or 1-800-434-1002 (NI). BH FAX: 973 -6324 or 1- 800- 293-4580Page 7 of 8
Page 3 of 3
ASAM DIMENSIONS (please explain all medium and high ratings)1. Alcohol Intox. And/or Withdrawal Potential
• Any risk of severe withdrawal/seizures?• Any current signs of withdrawal?
LOW MED HIGH EXPLAIN
2. Biomedical Conditions & Complications• Any current physical illness (besides withdrawal) that may
impact course of treatment?• Is member pregnant? Yes No
3. Emotional/ Behavioral or Cognitive Conditions & Complications• Any psych. Illness or psychological, behavioral, or emotional
problems that may impact the course of treatment?4. Readiness to Change (Treatment Acceptance/Resistance)
• Is the member objecting/resistant to treatment?• What is the member’s readiness to change?
5. Relapse (Continued Use Potential)• Is the member in immediate danger of continued severe
distress, and drinking/drug behavior?• Does the member have any understanding of, or skills in
which to cope with his/her addiction problems in order toprevent relapse/continued use?
6. Recovery Environment• Are there family members, significant others, living
situations, or school/work situations that pose a threat to TXengagement and success?
• Does the member have supportive friendships, financial,educational, or vocational resources that will increase thelikelihood of successful TX?
Provider Signature: ______________________________________Date:_______________________
LEVEL OF CARE DETERMINATION: **For AC Use onlyLOC DATE OF
REQUEST SESSIONS START DATE END DATE TX PLAN
DUE DATE TC DUE DATE
AUTH # CRITERIA USED
APPROVED: YES NO PARTIAL DATE OF DECISION: Reviewers signature____________________________ MD Signature:__________________________________
1357 Kapiolani Blvd., Ste. 1250, Honolulu, HI 96814. BH Phone: 973-‐2475 (Oahu) or 1-‐888-‐875-‐4979 (NI). BH FAX: 973-‐6324 or 1-‐800-‐293-‐4580
April 2016 Page 3 of 3
1357 Kapiolani Blvd., Ste. 1250, Honolulu, HI 96814. To contact the BH Dept., call 973-1650 (Oahu) or 1-800-434-1002 (NI). BH FAX: 973 -6324 or 1- 800- 293-4580
LEVEL OF CARE DETERMINATION: ** FOR AC Use Only
Page 3 of 3
ASAM DIMENSIONS (please explain all medium and high ratings)1. Alcohol Intox. And/or Withdrawal Potential
• Any risk of severe withdrawal/seizures?• Any current signs of withdrawal?
LOW MED HIGH EXPLAIN
2. Biomedical Conditions & Complications• Any current physical illness (besides withdrawal) that may
impact course of treatment?• Is member pregnant? Yes No
3. Emotional/ Behavioral or Cognitive Conditions & Complications• Any psych. Illness or psychological, behavioral, or emotional
problems that may impact the course of treatment?4. Readiness to Change (Treatment Acceptance/Resistance)
• Is the member objecting/resistant to treatment?• What is the member’s readiness to change?
5. Relapse (Continued Use Potential)• Is the member in immediate danger of continued severe
distress, and drinking/drug behavior?• Does the member have any understanding of, or skills in
which to cope with his/her addiction problems in order toprevent relapse/continued use?
6. Recovery Environment• Are there family members, significant others, living
situations, or school/work situations that pose a threat to TXengagement and success?
• Does the member have supportive friendships, financial,educational, or vocational resources that will increase thelikelihood of successful TX?
Provider Signature: ______________________________________Date:_______________________
LEVEL OF CARE DETERMINATION: **For AC Use onlyLOC DATE OF
REQUESTSESSIONS START DATE END DATE TX PLAN
DUE DATETCDUE DATE
AUTH # CRITERIA USED
APPROVED: YES NO PARTIAL DATE OF DECISION: Reviewers signature____________________________ MD Signature:__________________________________
April 2016 Page 3 of 3
1357 Kapiolani Blvd., Ste. 1250, Honolulu, HI 96814. To contact the BH Dept., call 973-1650 (Oahu) or 1-800-434-1002 (NI). BH FAX: 973 -6324 or 1- 800- 293-4580
April 2016 Page 8 of 8