Please print clearly mtcc contracted provider




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MEDICAID TREATMENT CHILD CARE PROGRAM
Statement of Medical Necessity

PLEASE PRINT CLEARLY







MTCC CONTRACTED PROVIDER

     

MTCC SITE

     

MTCC ADDRESS

     

CITY

     

STATE

     

ZIP CODE

     

CONTACT PERSON

     

TELEPHONE NUMBER

     

REFERRING AGENCY

 Children’s Administration  Public Health Nurse  Economic Services Administration

CHILD’S NAME

     

DATE OF BIRTH

     

AGE

     

DATE OF ADMISSION

     

EPSDT DATE

     

CHILD ID NUMBER

     

ASSESSMENT DATES

PARENT - CHILD OBSERVATION

     

FAMILY ASSESSMENT

     

CLINICIAN OBSERVATION

     

CLINICIAN OBSERVATION

     

CLINICIAN OBSERVATION

     

DEVELOPMENTAL ASSESSMENT

     

DIAGNOSES AND TOOLS USED TO DETERMINE THE ASSIGNED DIAGNOSES


Please check one of the boxes below:
 Diagnostic Classification of Mental Health and Developmental Disorders of Infancy Early Childhood: Revised Edition (DC: 0-3R) (up to 48 months)
 Diagnostic and Statistical Manual of Mental Disorders (DSM DSM-IV diagnostic tool can be sued for children ages 0- 5 years old)
DIAGNOSTIC CODE

Child’s current diagnoses with current severity.

AXIS I      

AXIS II      

AXIS III      

AXIS IV      



AXIS V      


Please describe the child’s symptoms that meet medical necessity and diagnostic criteria:




Please provide narrative (outcomes) of parent child observations and family assessment:




Please write narratives in each field below.

Duration of Child’s Symptoms:




Describe Child’s Symptoms:




Level of Acuity:




Child Safety Issues:




Parental Participation:




Anticipated Outcomes:




Anticipated Duration of Treatment:




MTCC CERTIFICATION AND SIGNATURES

By signing below, I certify all the information I have provided concerning this child is correct and accurately reflects that Medicaid Treatment Child Care mental health services are medically necessary to treat psychosocial disorders of this child.

LICENSED PRACTITIONER NAME/LICENSE #

     

LICENSED PRACTITIONER TITLE

     

LICENSED PRACTITIONER SIGNATURE

DATE

     




13-003 (REV. 10/2011)


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