Child/adolescent Psychiatric Service Form Page 2
Download a blank fillable Child/adolescent Psychiatric Service Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Child/adolescent Psychiatric Service Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4Physician and Facility Information
¨ Initial Request
¨ Concurrent Review
Ordering Physician/Practitioner: ________________________________________________________________
Provider Tax Number ________________________________________________/NPI: ____________________
Phone Number: ________________________________________________________
Fax Number:___________________________________________________________
Date of Order: _________________________________________________________
Certificate of Medical Necessity:
1
st
Certificate of Need (CON): Date _____________________________________ Time ____________________
2
CON: Date _____________________________________________________ Time ____________________
nd
Facility Name: ______________________________________________________________________________
Provider Tax ID Number: _____________________________________________/NPI: ____________________
Address: ___________________________________________________________________________________
__________________________________________________________________________________________
Phone Number: ________________________________________________________
Fax Number: ___________________________________________________________
Utilization Review (UR) Contact: ________________________________________________________________
UR Phone Number: _____________________________________________________
Requested Start Date: __________________________ Date of Evaluation/Assessment: ____________________
Clinical Information
*Date of Admission: _________________________________ *Date of last assessment: ____________________
Presenting problem (behavioral description of issues, current symptoms): ________________________________
__________________________________________________________________________________________
*Suicidal/Homicidal? q YES q NO If yes, describe ideation, plan, intent, means, history of Suicidal ideations/
homicidal ideations (SI/HI) attempts, treatment. ____________________________________________________
__________________________________________________________________________________________
Precipitant (What stressors led to this? Why now?): ________________________________________________
__________________________________________________________________________________________
This facsimile contains privileged and confidential information intended only for the use of the specific individual or entity named above. If you or
your employer are not the intended recipient of this facsimile (or an agent responsible for delivering it to the intended recipient), you are hereby
notified that, any unauthorized distribution or copying of this facsimile for the information contained in it, is strictly prohibited. If you have received
this facsimile in error, please immediately notify the person named above by telephone and return the original facsimile to the above address via
the U.S. Postal Service. Thank You.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business