Magellan Health Services/DDD CCCT Referral Form

Magellan Health Services/DDD CCCT Referral Form

Community Collaborative Care Teams

AHCCCS Medical Policy Manual Chapter 500/Policy 570

Date:

This form is designed to provide information for the CCCT referral process. The CCCT Referral policy is designed for ALTCS/DDD members who demonstrate inappropriate sexual behaviors and/or aggressive behaviorsonly, and who have been unresponsive to traditional ALTCS and Behavioral Health services and who have a (a) co-occurring behavioral health condition OR (b) a co-occurring physical health condition.

Any behavioral health provider or DDD Regional/District representative may refer a member for consideration to a RBHA/DDD CCCT.

DEMOGRAPHIC INFORMATION:

Member Name: ______DOB: ______

Parent/Guardian:______

Other Agency Contact Information: ______

______

Cultural/Language Considerations (specify) ______

______

HEALTH PLAN INFORMATION:

AHCCCS ID: ______Health Plan:______

PCP Name and Contact Information: ______

Other Insurance: Yes_____ No______If yes, name other Insurance: ______

______Medicare: Yes_____ No______

Name of Medicare Plan & Medicare ID______

Medicare D Yes_____ No_____ Name of Medicare D Plan______

DME/Specialty/Dental Provider______

Inpatient Status: ______

Recent hospitalizations (medical or behavioral)______

CLINICAL INFORMATION:

Diagnosis:

AXIS I______AXIS II______

AXIS III______AXIS IV______

GAF Score if Known______

Medications:______

______

Please attach last six months of medical and psychiatric records.

Medical History: ______

______

______

Last Known PCP Visit/History and Physical: ______

Current Place of Residence: Home:____ DDD______B/H_____ Community______

Court Ordered: Yes_____No_____ If yes: PAD_____ GAD_____ Date: ______

Guardian: Self_____Family member_____Pub Fid_____ Other______

SMI: Yes_____ No_____ ACT Team Services in Place: Yes _____ No_____

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PRESENTING ISSUES OF SEXUALLY INAPPROPRIATE AND AGGRESSIVE BEHAVIOR: Please give specific description of target behaviors that are causing member to be unable to function adequately in his or her present community setting with current services in place.

______

______

______

______

______

______

Recent crisis events: Yes_____No_____ Dates: ______

ARCP/Crisis Plan: Yes_____ No_____ Date of last Crisis Plan:______

DD/ISP: Yes_____ No _____ Date of DD/ISP ______

Person Centered Plan: Yes_____ No_____ Date of last Person Centered Plan______

BH PNO or Provider: ______

High Needs Case Manager: Yes_____ No_____ Name of HNCM______

SMI Case Manager Name and Contact Information:______

______

DDD Support Coordinator Name and Contact Information: ______

______

DDD Vendor Agency: ______

Functional Behavioral Assessment: Yes_____No______If yes, when______

DDD services in place______

______

Behavioral health services in place:______

______

______

Medical services in place (e.g. DME, specialty services, oxygen, dialysis, home health, etc.): ______

______

RECOMMENDED FOLLOW-UP CARE AND/OR ACTIVITY:

Behavioral Health Services: ______

______

______

______

______

DDD: ______

______

______

______

Comments: ______

______

______

______

Submitted by(please print):______Date: ______

Signature: ______

Title:______

Please complete this form and fax it to Magellan Health Services at: 1-800-424-4270

TO BE COMPLETED BY THE MAGELLAN DD LIAISON ONLY:

DISPOSITION OUTCOME:

Date of referral receipt: ______

Referred for CCCT Yes_____ No_____ Date: ______

Date of Disposition to referral source with recommendations: ______

______

______

Effective Date: 5/23/2013 CCCT Referral Form