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Outpatient Substance Abuse Rehabilitation Treatment Plan Form Mobile App

The Outpatient Substance Abuse Rehabilitation Treatment Plan Form standardizes the submission of a treatment plan to insurance providers. The form details Member and Provider Information, a Diagnosis, along with DSM codes for mental health treatment, existing drug abuse and alcohol abuse history, treatment history, support systems in place, a treatment plan, and the patient's responses to treatment in the past, including inpatient treatment, outpatient drug rehab, other types of drug rehab, mental health treatment, and medication based treatment. Any treatment program or treatment center seeking reimbursement from insurance providers could benefit from this form when engaging in intensive outpatient programs.

This form is best utilized in outpatient programs for drug rehab and drug addiction. Treatment centers that specialize is drug abuse and alcohol abuse can submit mental health diagnoses to insurance companies in order to seek reimbursement for a treatment center's outpatient program, or any other intensive outpatient program including residential treatment, rehab treatment, drug treatment, alcohol rehab, group therapy, and other substance abuse treatment programs with a focus on outpatient care.

  • Lendlease
  • The Cooperative
  • PG&E
  • oxy
  • Red Bull
  • Mirvac

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Take a peek inside the Outpatient Substance Abuse Rehabilitation Treatment Plan Form Mobile App

Included Features

Our App Builder gives you the power to easily add and remove the ones you want. {{controller.show_all ? 'See included features.' : 'See more features.'}}

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico textbox

    Treating provider:

  • Ico textbox

    Provider ID #:

  • Ico textbox

    Provider phone number:

  • Ico textbox

    Provider fax number:

  • Ico textbox

    Member ID #:

  • Ico textbox

    Reference #:

  • Ico textbox

    Member initials:

  • Ico date

    Date of Evaluation:

  • Ico integer

    Member Age:

  • Ico date

    Date of First Session:

  • Ico integer

    Number of Sessions Since Start of Treatment:

  • Ico dropdown

    Has Member given approval to contact his/her PCP?

  • Ico dropdown

    Have you contacted the Member’s PCP?

  • Ico dropdown

    DSM Axis

  • Ico textbox

    Substance Abuse/Psychiatric:

  • Ico textbox

    Past Year:

  • Ico textbox

    Current Year:

  • Ico dropdown

    Substance

  • Ico textbox

    Other Substance:

  • Ico textbox

    Age of First Use:

  • Ico textbox

    Frequency of Abuse:

  • Ico textbox

    Amount Used:

  • Ico textbox

    Date Last Used (Best Estimate):

  • Ico textbox

    Additional Information:

  • Ico dropdown

    Has Use Impacted/Jeopardized:

  • Ico dropdown

    Substance abuse treatment(s):

  • Ico textbox

    Other:

  • Ico textbox

    Duration of Inpatient Detox treatment:

  • ...and More!

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