Lawrencecounty - Independent Prescriber Registration Form

VALUE BEHAVIORAL HEALTH OF PENNSYLVANIA - A VALUEOPTIONS COMPANY

LAWRENCECOUNTY - INDEPENDENT PRESCRIBER REGISTRATION FORM

Complete this form for ALL evaluations or re-evaluations that have been scheduledfor a HealthChoices member (or parent) requesting a Child/Adolescent Evaluationand fax to 1-855-439-2448 Attn: Billie Jo.

If a member (or parent) calls and you are unable to schedule a timely appointment please assist the caller with a warm phone transfer to VBH-PA so a Member Services Representative can assist with scheduling an appt. The VBH-PA toll-free Member Services phone number for LawrenceCounty is: 1-877-688-5975.

Member Name: / Member DOB:
Member Address:
Member County: LAWRENCE / Member MA ID#:
Member Phone#:
Parent/Guardian: / Referring Agency or other referral source (if applicable):
Prescriber Name: Choose from drop down list:Bennett, Alan Craig, RobertCurrie, EdwardDavis, MaryDeLuigi, DominicLimerick-Gnas, ShannonLivingston, FredLuce, CarolMarston, DanielMcKnight-Krynski, JudithMerritt, ScottNewman, T. DavidPaglia, Barbara A.Pedone, AnthonyPelphrey, AmandaRein, JudiShreffler, MichaelSnyder, MarkStern, CaroleStern, MichaelUber, JohnWallace, KathleenWhitsel-Anderson, StephanieWiens, Lisa E. / Agency Name: Choose from drop down list:Bennett, Alan Ph.D.Craig, Robert Ph.D.Currie, Edward Ph.D.Davis, Mary Ph.D.DeLuigi, Dominic Ph.D.Limerick-Gnas, S MALivingston, Fred MALuce, Carol Ph.D.Marston, Daniel Ph.D.McKnight-Krynski, J Ph.D.Merritt, Scott MANewman, T. David Ph.D.Paglia, Barbara Ph.D.Pedone, Anthony MAPelphrey, Amanda Ph.D.Rein, Judi Ph.D.Shreffler, Michael Ph.D.Snyder, Mark MAStern, Carole MSStern, Michael Ph.D.Uber, John Ph.D.Wallace, Kathleen Ph.D.Whitsel-Anderson, S Ph.D.Wiens, Lisa E Ph.D.
or enter name: / or enter name:
FILL OUT THIS SECTION FOR INITIAL EVALUATIONS ONLY
Date Member Called Requesting Initial Evaluation:
Was an appointment offered within 7 business days of the member’s call? Yes No

• If yes, and appointment was scheduled, date of scheduled initial evaluation :

OR

• If an initial evaluation appointment was offered within 7 business days, but not scheduled within 7 days, indicate date of appointment and reason why: Date of Scheduled Appointment:

Reason not scheduled within 7 days: Family Choice Transportation Issues
Other
If “NO” (IP not available to schedule within 7 business days), member is to be offered the option of choosing another independent prescriber

• If no, and member was offered option of another IP, but chose to wait for later appointment date, enter date of scheduled evaluation here:

……………………………………………………………………………………………………………………PLEASE COMPLETE THIS SECTION FOR BOTH INITIALS & REEVALUATIONS

Date of Scheduled Evaluation: / (Check if: No Show Cancelled but not rescheduled)
Initial Evaluation / Reevaluation OR / Initial Reevaluation (1st time seen by Prescriber)
# of Units Requested for Evaluation / CHECK IF A RETRO-AUTHORIZATION
Recommended LOC: BHRS FBMHS / ONLY for Addendums:
RTF CRR PHP CASE MGT. / Date of Addendum:
MST OP MH OP D&A NO TSS / Units Requested for Addendum:
SBBH OTHER:* / Service being recommended:
*Do not indicate “SEE EVALUATION” if an “other” LOC/service is recommended – please write down the service(s).

Once evaluation is completed, fax this form and the completed evaluation toVBH-PA at 1-855-439-2448 Attn: Billie Joand to Lawrence County MHDSat 724-654-5230within seven (7) business days of the evaluation. This form also needs to be submitted if there was a no-show or canceled/not rescheduled appointment.

Revised 6/18/15