Clinical Update Request - Blue Cross Blue Shield Of Texas
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1
2FOCUSED OUTPATIENT
MANAGEMENT PROGRAM
Clinical Update Request
Instructions: Please fill out and print, or print form and fill out legibly in black ink. Fax to BCBSTX at 877-361-7646.
To speak to a Behavioral Health Outpatient Care Coordinator, call 800-528-7264.
Date_______________________________
c Initial Clinical Submission c Subsequent Clinical Submission
Patient and Member Information
Subscriber Name___________________________________________
Patient Name___________________________________________________
Subscriber ID #________________________________________________
Date of Birth___________________________________________________
Group #_____________________________________________________
Provider Information (Individual and/or Group)
Provider Name_____________________________________________
License_________________________ NPI #________________________
Address______________________________________________________
City____________________________ State_______ Zip_______________
Email Address__________________________________________________
Phone #________________________ Fax #________________________
Current DX — Please include all DSM 5 and/or medical diagnoses that apply.
Code #: _______________________ DX Name: ________________________________ Specifier: _____________________________________
Code #: _______________________ DX Name: ________________________________ Specifier: _____________________________________
Code #: _______________________ DX Name: ________________________________ Specifier: _____________________________________
Code #: _______________________ DX Name: ________________________________ Specifier: _____________________________________
Code #: _______________________ DX Name: ________________________________ Specifier: _____________________________________
Is the member on medications?
c No
c Yes
If yes, what are current medications/dosages?
What has been the response to medications?
c Poor c Moderate c Excellent _______________________________________________________
History of Services with Dates (Recent hospitalizations, PHP, IOP, OP, etc.):
Member began treatment with you on what date? ________________
What has response been to therapy?
c Poor c Moderate c Excellent
What are the current active symptoms being treated?
Has the member been screened for substance abuse issues? c No
c Yes
If yes, please give details of substance abuse (type of drug, duration of use, last use, episodes of treatment).
If no substance abuse screening, then why?
55599.0915
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