http://www.wordwendang.com/en/ - free word documents download |
tags list| Favorite

Current location: Word document > health >
CERTIFICATION OF SERIOUS AND PERSISTENT MENTAL ILLNESS _CERT
Updated:2011-11-23 Category:illness
Snapshot of the Word file:"CERTIFICATION OF SERIOUS AND PERSISTENT MENTAL ILLNESS _CERTIFICATION OF SERIOUS AND PERSISTENT MENTAL ILLNESSInstructions: This form ma".doc

CERTIFICATION OF SERIOUS AND PERSISTENT MENTAL ILLNESS

Instructions: This form may be used when you are unable to re-release a diagnostic assessment done by another entity to South Country Health Alliance for the purpose of MH-TCM Eligibility Determination Notifications. The form should be faxed to: SCHA 507-431-6329. Attention, MH/CH Manager

I have reviewed the diagnostic assessment submitted and the person meets the following criteria (check all that apply):

Member Name: DOB: PMI: ☐ This person does not have a serious and persistent mental illness as defined in Minnesota Statute 245.462, subd. 20. ☐ This person does have a serious and persistent mental illness as defined in Minnesota Statute 245.462, subd. 20 that states: For the purposes of case management and community support services, a “person with serious and persistent mental illness” means an adult who has a mental illness and meets at least one of the following criteria: ☐

☐ ☐ ☐

☐

☐

☐

☐

☐

    the adult has undergone two or more episodes of inpatient care for a mental illness within the preceding 24 months; the adult has experienced a continuous psychiatric hospitalization or residential treatment exceeding six months’ duration within the preceding 12 months; the adult has been treated by a crisis team two or more times within the preceding 24 months; the adult:
      has a diagnosis or schizophrenia, bipolar disorder, major depression, or borderline personality disorder; indicates a significant impairment in functioning; and has a written opinion from a mental health professional, in the last three years, stating that the adult is reasonably likely to have future episodes requiring inpatient or residential treatment, of a frequency described in clause (1) or (2), unless ongoing case management or community support services are provided;
    the adult has, in the last three years, been committed by a court as a person who is mentally ill under chapter 253B, or the adult’s commitment has been stayed or continued; or the adult: (i) was eligible under clauses (1) to (5), but the specified time period has expired or the adult was eligible as a child under section 245.4871, subd. 6; and (ii) has a written opinion from a mental health professional, in the last three years, stating that the adult is reasonably likely to have future episodes requiring inpatient or residential treatment, of a frequency described in clause (1) o (2), unless ongoing case management or community support services are provided.
☐ If clause (4) or (6) above was selected, a written opinion from a mental health professional was included.

Date of DA:

Person completing the diagnostic assessment:

Diagnoses: Primary Diagnosis Axis I

Axis II

DSM Code:

DSM Code

Secondary Diagnosis Axis I

Axis II

DSM Code:

DSM Code

Signature (to be completed by MH professional) Name: Signature: Date: Phone:

9/09


...For more information, Please download the word document.
Word file "CERTIFICATION OF SERIOUS AND PERSISTENT MENTAL ILLNESSInstructions: This form ma" Free Download Address
Click here to download the word document:CERTIFICATION OF SERIOUS AND PERSISTENT MENTAL ILLNESS .doc

Note
URL: http://www.wordwendang.com/en/word_health/23112011/35207.html
------division-----
Category list
Latest word documents
Hot word documents