Form CH-006: PA-BH-Res-PCS, Oregon Behavioral Health Support Program Plan of Care Authorization (Plan of Care Request for Behavioral Health Residential or Personal Care Services) Instructions

Enter the full name and professional title of the Community Mental Health Program (CMHP) representative who is signing the form.

Enter the date the CMHP representative signed the form.

Enter the start date when the service period begins for this referral.

Enter the end date when the service period ends for this referral.

Enter the legal guardian's full name (first and last; include middle name or initial if applicable). Fill only if 'Voluntary by Guardian' is 'Yes'.

Enter the guardian's relationship to the individual (for example: parent, grandparent, court‑appointed guardian, power of attorney). Fill only if 'Voluntary by Guardian' is 'Yes'.

Enter the guardian's complete mailing address, including street address, city, state, and ZIP code. Fill only if 'Voluntary by Guardian' is 'Yes'.

Enter the guardian's primary phone number, including area code and extension if applicable. Fill only if 'Voluntary by Guardian' is 'Yes'.

Enter the guardian's email address for contact. Fill only if 'Voluntary by Guardian' is 'Yes'.

Check this box when the individual or their guardian is aware that this referral is being submitted on their behalf.

Check this box when the individual or their guardian is NOT aware that this referral is being submitted on their behalf.

Enter the individual's legal last (family) name exactly as it appears on official records.

Enter the individual's legal first (given) name exactly as it appears on official records.

Provide the individual's date of birth.

Enter the individual's primary ICD-10 diagnosis code used for their current diagnosis or treatment.

Enter the individual's Medicaid identification (prime number) exactly as shown on Medicaid documentation, including any leading zeros.

Check this box if the individual is voluntarily receiving services (not under any legal order or guardian authority).

Check this box if the individual is receiving services voluntarily on the decision or consent of their legal guardian.

Check this box if the individual is under a civil commitment order.

Check this box if the individual is under the jurisdiction of the Psychiatric Security Review Board (PSRB).

Check this box if the individual is detained or designated under the 370 Aid and Assist statute for evaluation or competency purposes.

Check this box when the client's level of care is AFH.

Check this box when the client's level of care is RTH.

Check this box when the client's level of care is SRTF.

Check this box when the client's level of care is DD AFH.

Check this box when the client's level of care is DD Group Home.

Check this box when the client's level of care is APD AFH.

Check this box when the client's level of care is APD RCF.

Check this box when the client's level of care is TAY RTH.

Check this box when the client's level of care is TAY RTF.

Check this box when the client's level of care is Independent Living.

Check this box when the client's level of care is APD Assisted Living Facility (ALF).

Check this box when the client's level of care is RTF.

Check this box when the HK modifier applies to the procedure/service being billed.

Check this box when the HE modifier applies to the procedure/service being billed.

Check this box when the TG modifier applies to the procedure/service being billed.

Check this box when the HW modifier applies to the procedure/service being billed.

Enter the total number of units requested for the full duration of service.

Check this box when the service provided should be billed using procedure code T1020.

Check this box when the service provided should be billed using procedure code S5140.

Check this box when the service provided should be billed using procedure code S5141.

Check this box when no procedure code applies because the client is in Independent Living (N/A). Fill only if 'Independent Living' is selected.

Enter the full name and professional title of the provider or staff member submitting this form.

Enter the date when the provider or staff member signed and submitted this form.

Enter the full name of the referring provider or organization, including professional credentials (e.g., MD, RN) if applicable.

Enter the referring provider's MCD (Medicaid) number as assigned by the state payer.

Enter the primary business phone number for the referring provider including area code and any extension.

Enter the referring provider's professional email address for correspondence about this referral.

Enter the referring provider's business fax number including area code, if available.

Enter the full name of the rendering provider, including first and last name and any professional credentials as needed.

Enter the provider's MCD (Medicaid/Medical Care) identification number exactly as issued, including any letters or leading zeros.

Enter the rendering provider's primary phone number including area code and extension if applicable.

Enter the rendering provider's email address to be used for contact and correspondence.

Enter the rendering provider's fax number, including area code if available.

Enter the individual's date of admission to the residential program if applicable.

Enter the name of the county responsible for the individual's case or services.

Enter the name of the individual's Coordinated Care Organization responsible for care coordination.

Check this box when submitting an initial request for admission; the referral is accepted upon admission.

Check this box when this submission is the annual redetermination; referrals are accepted beginning 60 days prior to the end of the current plan of care.

Check this box when requesting a 90-day SRTF reauthorization; referrals are accepted beginning 30 days prior to the end of the current plan of care.

Check this box when requesting due to a change in the individual's condition; referrals are accepted after at least 30 days following the change in status.

Check this box if you are providing a Risk Management Plan that identifies risks (for example: suicide, choking, fall, elopement) for the consumer.

Check this box if you are including a Mental/Behavioral Health Assessment signed by a QMHP dated within one year of the service start date for the current authorization.

Check this box if you are attaching the Residential Care Plan and/or Treatment Plan that addresses all behavioral health service needs and is dated within one year of the authorization start date.

Check this box if the consumer is involved with the Psychiatric Security Review Board and you are providing the Conditional Release or Community Evaluation documentation.

Check this box if legal guardianship paperwork applies to the consumer and you are including copies of that documentation.

Check this box if you are including progress notes for AFH, RTH, or RTF: 6–12 months if monthly/weekly, or the most recent 60 days if daily.

Check this box if you are including daily clinical, nursing and psychiatric progress notes from SRTF covering the most recent 90 days.

Check this box if you are including progress notes documenting a change in condition or status for periods of 30 days or more.

Check this box if the placement is APD/DD and you are including the facility's APD/DD license documentation.

Check this box if there are relevant incident reports to include with the authorization request.

Check this box if you are including Nursing Delegation Form(s) CH-011 and any related supporting documentation.

Check this box if you are including a signed consent for release of information and participation in the Oregon Behavioral Health Support Program (signed by guardian if applicable).