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- "Kentucky Checklist for the Identification of Co-occurring Behavioral Health and Chronic or Complex Physical Health Condition" - Kentucky
"Kentucky Checklist for the Identification of Co-occurring Behavioral Health and Chronic or Complex Physical Health Condition" - Kentucky
Kentucky Checklist for the Identification of Co-occurring Behavioral Health and Chronic or Complex Physical Health Condition is a legal document that was released by the Kentucky Department for Behavioral Health, Developmental and Intellectual Disabilities - a government authority operating within Kentucky.
Form Details:
- Released on February 28, 2020;
- The latest edition currently provided by the Kentucky Department for Behavioral Health, Developmental and Intellectual Disabilities;
- Ready to use and print;
- Easy to customize;
- Compatible with most PDF-viewing applications;
- 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 Kentucky Department for Behavioral Health, Developmental and Intellectual Disabilities.
Download "Kentucky Checklist for the Identification of Co-occurring Behavioral Health and Chronic or Complex Physical Health Condition" - Kentucky
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1Kentucky Checklist for the Identification of Co-Occurring
Behavioral Health and Chronic or Complex Physical Health Condition
___________________________ _______________________ ________________________________
Individual’s Name
Identification Number
Diagnostic Code(s)
The following table illustrates the criteria that shall be met for an individual to be designated as qualifying for targeted
case management for co-occurring Behavioral Health (SMI, SED, SUD) and a Chronic or Complex Physical Health
Condition(s).
YES
NO
CRITERIA
Designation of Behavioral Health Conditions (Check all that apply):
SED _______,
SMI _______,
SUD _______
as determined and documented by a licensed behavioral health professional on
______________.
Date
YES NO
2. Chronic or Complex Physical Health Conditions: Means that significant symptoms of
a physical health condition have persisted in the individual for a continuous period of at
least two (2) years, or that the individual has been hospitalized as a result of this
physical health condition for more than once in the last two (2) years, AND
a) That the symptoms of the physical health condition presently significantly
impair the individual in his/her ability to function socially,
educationally/occupationally, or both.
b) Physical Health Conditions: For the purposes of this regulation, these physical
health conditions may include disorders under the following categories:
a. Cardiovascular Disorders
b. Respiratory Disorders
c. Genito-Urinary Disorders
d. Endocrine Disorders
e. Musculoskeletal Disorders
f. Neurological Disorders
g. Immune System Disorders
h. Gastrointestinal Disorders
i.
Hematological Disorders
Note: Documentation of the existence of these criteria is present in the individual’s medical record
(documented and signed/dated behavioral health assessment has been conducted by a qualified,
licensed behavioral health professional) and with the Physical Health diagnosis (documented and
signed/dated has been made by a qualified medical professional).
______________________________/_________________________________
___________________
Print Name/Credentials
Signature
Date
2/28/2020
Kentucky Checklist for the Identification of Co-Occurring
Behavioral Health and Chronic or Complex Physical Health Condition
___________________________ _______________________ ________________________________
Individual’s Name
Identification Number
Diagnostic Code(s)
The following table illustrates the criteria that shall be met for an individual to be designated as qualifying for targeted
case management for co-occurring Behavioral Health (SMI, SED, SUD) and a Chronic or Complex Physical Health
Condition(s).
YES
NO
CRITERIA
Designation of Behavioral Health Conditions (Check all that apply):
SED _______,
SMI _______,
SUD _______
as determined and documented by a licensed behavioral health professional on
______________.
Date
YES NO
2. Chronic or Complex Physical Health Conditions: Means that significant symptoms of
a physical health condition have persisted in the individual for a continuous period of at
least two (2) years, or that the individual has been hospitalized as a result of this
physical health condition for more than once in the last two (2) years, AND
a) That the symptoms of the physical health condition presently significantly
impair the individual in his/her ability to function socially,
educationally/occupationally, or both.
b) Physical Health Conditions: For the purposes of this regulation, these physical
health conditions may include disorders under the following categories:
a. Cardiovascular Disorders
b. Respiratory Disorders
c. Genito-Urinary Disorders
d. Endocrine Disorders
e. Musculoskeletal Disorders
f. Neurological Disorders
g. Immune System Disorders
h. Gastrointestinal Disorders
i.
Hematological Disorders
Note: Documentation of the existence of these criteria is present in the individual’s medical record
(documented and signed/dated behavioral health assessment has been conducted by a qualified,
licensed behavioral health professional) and with the Physical Health diagnosis (documented and
signed/dated has been made by a qualified medical professional).
______________________________/_________________________________
___________________
Print Name/Credentials
Signature
Date
2/28/2020
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