Referral Form What type of Claim is this? State Fund Self Insured Referral Type Behavior Health Intervention (BHI) Accepted Mental Health Diagnosis on Claim (MH) Has this worker completed BHI sessions previously with a different Provider? * Yes No Unknown If "Yes," provide approximate dates of service and provider name: Employer Date of Injury Claim # Client First Name Client Last Name Client Date of Birth Client Telephone # Client Email Address (used for scheduling) Client Address Your Relationship to Client VRC Attending Provider Medical Assistant OtherOther Your Name Your Phone Your Email All Accepted and Denied Conditions (include ICD codes) For BHI referrals, did the attending provider indicate approval / recommendation? Yes N/A - this is not a BHI referral *** Please attach completed questionnaire, APF, or chart note. For MH referrals, has treatment been authorized? Yes N/A – this is not a MH referral *** Please attach screen shot from CAC with the following psych codes authorized: 90832/90834/90837 (Therapy 30 min, 45 min, 60 min) Conversation with client? Yes - I have spoken with the client about this referral and they are expecting a call from the therapist (or interpreter) to schedule. Primary Language If English is second language, is it preferred that a therapist who speaks the client’s primary language be assigned? N/A Yes No preference Name and Contact Info for Preferred Interpreter* * If we don't have a therapist who speaks the primary language, please provide the contact info for an interpreter here. Preferred method of treatment: In-person Telehealth No preference *** Limited in-person sessions are available at this time Claims Manager Name Claims Manager Phone #: Vocational Rehabilitation Counselor VRC Phone # Attorney Rep Name Attorney Telephone # Attending Provider Name Attending Provider Telephone # Attending Provider Fax # Brief explanation of reason for referral (symptoms, situation/barriers, etc.) Upload Documents Drop a file here or click to upload Choose File Maximum file size: 268.44MB If you are human, leave this field blank. Submit
