Outpatient Treatment Progress Report at a glance
What it is: Outpatient Treatment Progress Report for United Behavioral Health MN-CMC.
Who signs: Under SIGN, the clinician signs the Clinician's Signature line and enters the Date.
A filled-in Outpatient Treatment Progress Report example: a therapist reports a member's progress
How to fill out Outpatient Treatment Progress Report, box by box
MEMBER INFORMATION
Print clearly. Under MEMBER INFORMATION, enter the Member Name (First & Last), the Member ID# and the Date of Birth.
Enter the Member Address and the (City/State).
Provider Name, Degree, Phone and Address
Enter the Provider Name, the Degree, the Phone and the Address.
Number of Sessions to date, Frequency, Date 1st Visit and Date Last Visit
Enter the Number of Sessions to date, the Frequency, the Date 1st Visit and the Date Last Visit.
Release of information
Mark Yes or No for Release of information for UBH signed.
Mark Yes or No for Release of information for PCP signed.
Mark TX Plan or Summary sent to patient's PCP, or Member/ Parent/Guardian refused consent for release to PCP, or Member states they have no PCP.
CURRENT MEDICATIONS
Under CURRENT MEDICATIONS, include all meds psychiatric and medical, each with its Drug, Current Dose and Duration.
Progress Update
Under Progress Update, mark one: Compliant, Progressing and Improving -Needs more sessions; Compliant, Progressing and Improving and Plan for discharge, with When?; Compliant, Not Progressing or Improving - Needs Med referral; Not Compliant, but at risk, with How addressed?; or Not Compliant, Needs Referral for other Services/ Therapy.
If Patient needs referral
If Patient needs referral, mark Have you made the referral? Yes No, Can UBH help you with the referral? and Would like to consult with a UBH clinician? MSW MA PhD MD.
Expected Outcome and Prognosis
Under Expected Outcome and Prognosis, mark one: Return to normal functioning; Expect improvement, anticipate less than normal functioning; Relieve acute symptoms, return to baseline functioning; or Maintain current status/prevent deterioration.
Enter the Frequency of sessions, the Expected LOS and the Modality CPT Code.
SIGN
Under SIGN, the clinician signs the Clinician's Signature line and enters the Date.
Common questions about Outpatient Treatment Progress Report
Where do I file it?
To request further certifications, fax or mail to United Behavioral Health MN-CMC MR:MN010-S155, P.O. Box 1459, Minneapolis, MN 55440-1459, Phone: 1-800-848-8327 (Toll Free Minnesota Location) or FAX (763)732-6910.
When is this form not the right one?
This form is to be used for routine outpatient psychotherapy only.
Sources
[1] Outpatient Treatment Progress Report (the Official source link on this page).