BCBST BH Referrals

REFERRAL FOR SERVICES
Individual Demographics

The below questions pertain to the individual to be seen.
Member Name*

First NameMiddle Name/InitialLast Name
Preferred Name (if different)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Member Contact Number*
Please enter a valid phone number.
Phone Number Type*

MobileHome
Member Date of Birth*

MonthDayYear
Date
Sex*

MaleFemale
Social Security Number (SSN)*
Marital Status
Individual's Email (If Individual has one)
example@example.com
Hearing Status*
Preferred Language / Mode of Communication*

EnglishASLSpanishSimComOther
Please indicate your Referral Source by clicking the circle below.

BlueCross BlueShield of Tennessee ECFBlueCross BlueShield of Tennessee BHAmerigroup ECFAmerigroup BHTN DIDDTN DCSOther
Please check line of business*

BlueAdvantage (PPO)SMBlueCare Plus (HMO SNP)SMCoverKidsBlueCareSMTennCareSelect
Member Number*
Insurance Identification Number
Date Request Sent

MonthDayYear
Date
Provider Name
Provider Phone
Provider Fax
UR Contact Name
UR Contact Phone
Clinician Provider ID #
Clinician NPI #
Clinician Address
Treating Clinician (list credentials)
Clinician Provider ID #
Clinician NPI #
Clinician Address
Requested Facility
Facility Provider ID #
Facility NPI #
Facility Address
Psychiatric ICD-10 Diagnosis Codes:
Code 1:
Code 2:
Code 3:
Code 4:
Code 5:
Medical ICD-10 Diagnosis Codes:
Code 1:
Code 2:
Code 3:
Code 4:
Code 5:
Requested Start Date of Service

MonthDayYear
Date
(Note: If start date is prior to the request received date, it must be requested as a retrospective review and may be denied for non-compliance
Contact information
Date when member initiated request for this service

MonthDayYear
Date
Name(s) of person(s) initiating this referral?*
Your Phone Number*

Area CodePhone Number
Your Email (if we have questions)*
example@example.com
Primary Care Provider (PCP)*

First NameLast Name
PCP Address (optional)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PCP Phone

Area CodePhone Number
PCP Fax (optional)

Area CodePhone Number
PCP Email
example@example.com
Reason for referral?*
Describe how proposed testing will clarify diagnosis and impact future behavioral treatment
This testing will be used to confirm diagnosis, make recommendations for service needs and identify strategies to improve the safety of the patient and the patients family.
Describe in detail the patient’s current condition and symptoms*
Treatment History*
Diagnosis:*
Please list all diagnoses currently active
Please answer all that apply

Leave blank if not applicable
Psychiatrist Name:
Psychiatrist Phone Number:
Therapist or BA's name:
Therapist or BA's Phone Number:
Conservator's Name (If none, enter NA):*
Conservator's Phone Number (If none, enter NA):*
Representative Payee (If applicable):
Representative Payee phone number:
SOS Coordinator Name:
SOS Coordinator phone number:
Is the individual enrolled in ECF Choices?*

YesNo
Does the individual have Medicare Coverage?*

YesNo
Does the individual have Medicare Advantage Coverage?*

YesNo
Does the individual have Medicaid Coverage?*

YesNo
Does the individual have Commercial Insurance Coverage?*

YesNo
Is DCS the Payor?*

YesNo
Primary Insurance*:*
Is DIDD the Payor?*

YesNo
Please upload the front of the Primary insurance card*

Front of card
Cancelof
Please upload the back of the Primary insurance card*

Back of Card
Cancelof
Does individual have a secondary insurance?*

YesNo
Please upload a copy of the front and back of any other insurance cards

Cancelof
Services requested*

Skills Training GroupIndividual TherapyPsychiatric Evaluation and ManagementAssessmentConsultation
Upload PCSP, ISP or current treatment plan*

Cancelof
Upload Medication List*

Cancelof

Prior Testing and Date of Last Testing:

	psychological, medical, psychiatric and neurological exams with results
Exam
Exam
Exam
Exam
Exam
Exam

Medications

	Medication	Dose	Frequency
Exam
Exam
Exam
Exam
Exam
Exam

Drug Allergies*
type NKDA if none
Previous psychological or psychiatric evaluation/BSP

Cancelof
Medication adherence? Barriers to adherence?
No concern
Substance abuse concerns?
No concern
If repeat testing is being requested, why is it needed at this time?
Evaluation Services (Note: One unit equals one hour

Integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning, report writing and feedback to patient/family member:
Service Activity
Time (units being requested)
Test Administration and Scoring (Note: One unit equals 30 minutes

Specific psychological tests being requested (full name of test written out) with specified time for each one:
Test Name
Time (units being requested)
Test Administration and Scoring (continued)
Test Administration and Scoring (continued)
Test Administration and Scoring (continued)
test_5
Total Units Being Requested
Signature of Ordering Clinician with Credentials (Required in order to process)
Signature of Ordering Clinician with Credentials (Required in order to process)
Signature of Ordering Clinician with Credentials (Required in order to process)
Signature of Ordering Clinician with Credentials (Required in order to process)
Date of Signature

MonthDayYear
Date
Please check the appropriate service you’re requesting

Psychological TestingNeuropsychological Testing
Should be Empty:

REFERRAL FOR SERVICES

Individual Demographics

Psychiatric ICD-10 Diagnosis Codes:

Medical ICD-10 Diagnosis Codes:

Contact information

Please answer all that apply