Initial Treatment Request

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

History of Illness (Indicate the frequency, severity, and duration of symptoms and be specific)

Suicidal Ideation

Yes Denies

Homicidal Ideation

Yes Denies

Psychiatric History

Medical History

Current Medication & Medication Allergies

Family and Social History

Current and Past Chemical Dependency (drugs, alcohol and/or prescription medication)

Discussed Medications (Side effects/Interactions/Risks/Benefits)

Yes No N/A

Psychiatric Diagnoses

Psychosocial Factors (check all that apply)

• Access to Health Care
• Housing
• Primary Support Group
• Economic
• Education
• Occupational
• Social Environment
• Other Psychosocial or Environmental
• Legal System/ Crime

Prognosis

Excellent Good Fair Poor

Anticipated treatment duration

Weeks Months

Outpatient Initial Treatment Request (ITR)  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
(99212, 99213, 99214) Medication Management
(90832, 90834, 90837) Psychotherapy
(90847) Family Therapy
(90853) Group Therapy
Please send Clinical Justification for all other CPT codes for outpatient treatment
Other:

Treatment plan for requested sessions

Next appointment date

Patient has consented for release of information to PCP

Yes No