BCBST BH Referrals

REFERRAL FOR SERVICES
Individual Demographics

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

First Name Middle Name/Initial Last Name
Preferred Name (if different)
Address *

Street Address

Street Address Line 2

City State / Province

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

Mobile Home
Member Date of Birth *

Month Day Year
Date
Sex *

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

English ASL Spanish SimCom Other
Please indicate your Referral Source by clicking the circle below.

BlueCross BlueShield of Tennessee ECF BlueCross BlueShield of Tennessee BH Amerigroup ECF Amerigroup BH TN DIDD TN DCS Other
Please check line of business *

BlueAdvantage (PPO)SM BlueCare Plus (HMO SNP)SM CoverKids BlueCareSM TennCareSelect
Member Number *
Insurance Identification Number
Date Request Sent

Month Day Year
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

Month Day Year
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

Month Day Year
Date
Name(s) of person(s) initiating this referral? *
Your Phone Number *

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

First Name Last Name
PCP Address (optional)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
PCP Phone

Area Code Phone Number
PCP Fax (optional)

Area Code Phone 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? *

Yes No
Does the individual have Medicare Coverage? *

Yes No
Does the individual have Medicare Advantage Coverage? *

Yes No
Does the individual have Medicaid Coverage? *

Yes No
Does the individual have Commercial Insurance Coverage? *

Yes No
Is DCS the Payor? *

Yes No
Primary Insurance*: *
Is DIDD the Payor? *

Yes No
Please upload the front of the Primary insurance card *

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

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

Yes No
Please upload a copy of the front and back of any other insurance cards

Cancel of
Services requested *

Skills Training Group Individual Therapy Psychiatric Evaluation and Management Assessment Consultation
Upload PCSP, ISP or current treatment plan *

Cancel of
Upload Medication List *

Cancel of

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

Cancel of
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

Month Day Year
Date
Please check the appropriate service you’re requesting

Psychological Testing Neuropsychological 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