Verification of Continued Medical Necessity

Client Name:     ______________________________________________    SS#:  ___________________

Client Current Address:______________________________________________________________________

DSM code:_________Diagnosis:__________________________________________

GAF at Initial Assessment: _______        Current GAF: ________________

Current Frequency of sessions:__________________________________

Provider Name:__________________________________________________           Phone:  _________________

Please check which of the following apply to the client:

 _____A. The original severity of illness and intensity of services criteria, present at the start of care continue to apply, and no less intensive level of treatment would be adequate

_____B. New symptoms have emerged and no less intensive level of treatment would be adequate. Please identify new symptoms and expected frequency of treatment:

_________________________________________________________________________________________

_________________________________________________________________________________________

______C. Symptom acuity and risk have significantly decreased so that a shift to another level of care appears imminent. Please indicate new level of care indicated (include reduced frequency of treatment) and expected date to begin

_________________________________________________________________________________________

Please respond legibly on a separate sheet with the following information:

What progress has been made with the client in relation to specific symptoms or impairment?

How have you evaluated with the client the treatment progress or lack of progress made?  What other types of treatment are indicated, such as psychiatric evaluation or Intensive Outpatient or Inpatient treatment?

Describe the level of engagement from the client and family (for example:  attendance, homework, relevant session content)

Please identify treatment goals and target symptoms, with expected time frame to meet goals:

What is the primary treatment modality being provided?  What other sources of intervention are being used by the client?

To access the level of care criteria, please refer to the provider section of the EAN website at www.eannc.com