Form HLTH2809 "Funding Application for out-Of-Province Mental Health and/or Addictions" - British Columbia, Canada

ADVERTISEMENT
ADVERTISEMENT

Download Form HLTH2809 "Funding Application for out-Of-Province Mental Health and/or Addictions" - British Columbia, Canada

Download PDF

Fill PDF online

Rate (4.4 / 5) 21 votes
FUNDING APPLICATION
FOR OUT-OF-PROVINCE
MENTAL HEALTH AND/OR ADDICTIONS
Send form to:
Out-of-Province Claims
Application must be completed by the attending psychiatrist or
2-1, 1515 Blanshard Street
addictions specialist with a recent consultation report attached.
Victoria BC V8W 3C8
Phone: 250 952-1891
Fax: 250 952-1940
PHYSICIAN
Referring Physician
Phone Number
Fax Number
Mailing Address
Signature of Referring Physician
Date Signed
PATIENT
Patient Last Name
Patient First Name
BC Personal Health (CareCard) Number
Birthdate
OUT-OF-PROVINCE TREATMENT PROGRAM
Facility Name
Facility Location (City, Province)
Program Name
Treatment Length (# of days)
DIAGNOSIS, ASSESSMENT AND MEDICAL HISTORY
1. Is the patient mentally alert, medically stable and able to participate in residential treatment?
Yes
No
If no, please explain:
2. Does the patient demonstrate significant impairment in functioning as a direct result of severe mental illness or substance abuse in
any of the following categories?
a) Social
Yes
No
b) Family
Yes
No
c) Occupational
Yes
No
If no in any or all of the above categories, please explain:
HLTH 2809 2016/10/20 PAGE 1 OF 4
FUNDING APPLICATION
FOR OUT-OF-PROVINCE
MENTAL HEALTH AND/OR ADDICTIONS
Send form to:
Out-of-Province Claims
Application must be completed by the attending psychiatrist or
2-1, 1515 Blanshard Street
addictions specialist with a recent consultation report attached.
Victoria BC V8W 3C8
Phone: 250 952-1891
Fax: 250 952-1940
PHYSICIAN
Referring Physician
Phone Number
Fax Number
Mailing Address
Signature of Referring Physician
Date Signed
PATIENT
Patient Last Name
Patient First Name
BC Personal Health (CareCard) Number
Birthdate
OUT-OF-PROVINCE TREATMENT PROGRAM
Facility Name
Facility Location (City, Province)
Program Name
Treatment Length (# of days)
DIAGNOSIS, ASSESSMENT AND MEDICAL HISTORY
1. Is the patient mentally alert, medically stable and able to participate in residential treatment?
Yes
No
If no, please explain:
2. Does the patient demonstrate significant impairment in functioning as a direct result of severe mental illness or substance abuse in
any of the following categories?
a) Social
Yes
No
b) Family
Yes
No
c) Occupational
Yes
No
If no in any or all of the above categories, please explain:
HLTH 2809 2016/10/20 PAGE 1 OF 4
3. Why is the patient unable to maintain sobriety and continuing to use substances despite active outpatient treatment in the
last three months?
4. Is partial hospitalization or intensive outpatient treatment medically appropriate now?
Yes
No
If no, please explain:
5. How would the patient’s current social and living environment sabotage attempts at outpatient treatment?
6. Has the patient been hospitalized in the past 10 years for addiction and mental health?
Yes
No
If yes, please provide details:
Program Name
Diagnosis
Admission and
Outcome
Discharge Date
A
D
A
D
A
D
If no, please explain:
HLTH 2809 2016/10/20 PAGE 2 OF 4
7. The referral for out-of-province treatment must be reviewed with the Regional Director responsible for Mental Health and Addiction
Programs in your regional health authority. The Regional Director contacted:
Name
Health Authority
Phone Number
Date
8. Is your patient a health care provider?
Yes
No
If so, is she/he currently licensed?
Yes
No
MULTIAXIAL FORMULATION
AXIS I - Clinical Disorders / Other Conditions that may be a focus of Clinical Attention
Diagnosis Code
DSM-IV Name
AXIS II - Personality Disorders / Intellectual Disability
Diagnosis Code
DSM-IV Name
AXIS III - General Medical Conditions
Diagnosis Code
DSM-IV Name
AXIS IV - Psychosocial and Environmental Problems - check all that apply and SPECIFY for any checked item.
Problems with primary support group ________________________________________________________________________________________
Problems related to the social environment ____________________________________________________________________________________
Educational problems _____________________________________________________________________________________________________
Occupational problems ____________________________________________________________________________________________________
Housing problems ________________________________________________________________________________________________________
Economic Problems _______________________________________________________________________________________________________
Problems with access to health care services ___________________________________________________________________________________
Other psychological and environmental problems ______________________________________________________________________________
AXIS V - Global Assessment of Functioning Scale
Score: _____________________________________
Time Frame: ________________________________
HLTH 2809 2016/10/20 PAGE 3 OF 4
ASAM LEVEL OF CARE MATRIX FOR PATIENTS WITH SUBSTANCE ABUSE
Dimension
Treatment Level
1. Acute Intoxication / Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional / Behavioural or Cognitive Conditions
4. Readiness to Change
5. Relapse, Continued Use or Continued Problem Potential
6. Recovery Living Environment
The personal information on this form is collected under the Freedom of Information and Protection of Privacy Act, Section 26 (c), and will be used to
assess the application for funding of out-of-province treatment. If you have any questions about the collection and use of this information, please contact
Out of Province Claims by mail at 2-1, 1515 Blanshard Street, Victoria, BC, V8W 3C8 or by phone at (250) 952-1891.
HLTH 2809 2016/10/20 PAGE 4 OF 4
PRINT
RESET
Page of 4