Progress Note/Follow up Treatment Request Psychiatric/Psychotherapy

Practitioner Information

Name		Licensure
Address		City
State		Zip Code
Phone Number		Fax Number

Patient Information

Name		Date of Birth
Date of Service		Medical Group
Referral Source		CPT
			Interactive Complexity 90785

Patient's Chief Complaint

Changes to Present Illness (Indicate the frequency, severity, and duration of symptoms and be specific)

Suicidal Ideation

Yes Denies

Homicidal Ideation

Yes Denies

Current Medications

Discussed Medication Risks/Benefits/Alternative Treatments

Yes No

Psychiatric Diagnoses

Disorder	ICD-10 Code

Prognosis

Excellent Good Fair Poor

Anticipated treatment duration

Weeks Months

Outpatient Follow-Up Treatment Request (FTR) Heritage Provider Network’s medical group will authorize up to six (6) sessions of MD/NP care or twelve (12) sessions of therapy per request

CPT Code	# Sessions Requested	Frequency
(90832) Individual Therapy 30 min
(90834) Individual Therapy 45 min
(90837) Individual Therapy 60 Min
(90847) Family Therapy
(90853) Group Therapy
(99212, 99213, 99214) Medication Management

Treatment plan for requested sessions

Next appointment date

Patient has consented for release of information to PCP

Yes No