"Managed Care Substance Abuse Screening and Referral Form" - Missouri

Managed Care Substance Abuse Screening and Referral Form is a legal document that was released by the Missouri Department of Mental Health - a government authority operating within Missouri.

Form Details:

  • The latest edition currently provided by the Missouri Department of Mental Health;
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  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Missouri Department of Mental Health.

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Download "Managed Care Substance Abuse Screening and Referral Form" - Missouri

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MANAGED CARE SUBSTANCE ABUSE
MO
HealthNet
SCREENING & REFERRAL FORM
MEMBER INFORMATION
PROVIDER INFORMATION
Name (Last, First, M.I.)
Date of Birth
Provider Name (affix label here)
Address (Street, City, State, Zip Code)
MO HealthNet
Address
Number
SSN
MO HealthNet Managed Care Health Plan
MO HealthNet Provider Number
Phone Number
Email
Date of Office Visit
Signature
Date
STEP 1
Does member:
 drink alcohol?
 use illegal drugs?
 abuse prescription medications?
What
prompted this
screening?
If pregnant, trimester of pregnancy:
 1
 2
 3
st
nd
rd
STEP 2
Yes
No
CAGE-AID
[CAGE Adapted to Include Drugs]
C
: Have you felt you ought to cut down on your drinking or drug use?
A
: Have people annoyed you by criticizing your drinking or drug use?
G
: Have you felt bad or guilty about your drinking or drug use?
E
: Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover
(eye opener)?
STEP 3
Disposition:
__________________________________
 Brief Intervention
 Referral: Referred to
and other pertinent information (attach separate sheet if necessary):
If referred, primary reason for referral
MANAGED CARE SUBSTANCE ABUSE
MO
HealthNet
SCREENING & REFERRAL FORM
MEMBER INFORMATION
PROVIDER INFORMATION
Name (Last, First, M.I.)
Date of Birth
Provider Name (affix label here)
Address (Street, City, State, Zip Code)
MO HealthNet
Address
Number
SSN
MO HealthNet Managed Care Health Plan
MO HealthNet Provider Number
Phone Number
Email
Date of Office Visit
Signature
Date
STEP 1
Does member:
 drink alcohol?
 use illegal drugs?
 abuse prescription medications?
What
prompted this
screening?
If pregnant, trimester of pregnancy:
 1
 2
 3
st
nd
rd
STEP 2
Yes
No
CAGE-AID
[CAGE Adapted to Include Drugs]
C
: Have you felt you ought to cut down on your drinking or drug use?
A
: Have people annoyed you by criticizing your drinking or drug use?
G
: Have you felt bad or guilty about your drinking or drug use?
E
: Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover
(eye opener)?
STEP 3
Disposition:
__________________________________
 Brief Intervention
 Referral: Referred to
and other pertinent information (attach separate sheet if necessary):
If referred, primary reason for referral