Appendix E
Personal Health Information Requested by MCOs and MBHOs

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Patient Health Information Commonly Requested in Outpatient Treatment Request Forms,
By Type of Response. MCOs Only -
Total Examined – 4

Requested Information(1)	Categorical	Narrative	Both
Demographic/Administrative Information
Patient’s Name		4
Patient’s Date of Birth		4
Patient’s Social Security/Insurance ID number		4
Practitioner’s Name, Address, Phone		4
Practitioner’s License and/or ID number		4
Initial Authorization or Continuing	4
Length of Treatment/Start and End Dates		2
Diagnosis
DSM-IV Diagnosis Code	4
Current Global Assessment of Functioning (GAF)	4
Highest GAF in past year	3
Patient History
Previous MH/SA Treatment	2	2	1
History of Substance Abuse		2
Level of Functioning
Symptoms	1	1	2
Duration and Severity of Symptoms	2	1
Risk Assessment Suicide/Homicide			2
Current Substance Abuse	1		2
Family/Social Relationships	1	1	1
Job/School Performance	1	1	1
Obsessions/Compulsions	1		1
Treatment Information
Requested Procedures/Types of Services	3		1
Frequency/Duration of Treatment	2	2
Expected Treatment Outcomes	1	3
Member Notified/Concurs with Goals?	2	1
Medications
Current Medications	1	3
Dosage/Frequency		3
Compliance	1	1
Care Coordination
Communication with PCP	3
Patient Receiving Other Community Services		3

Patient Health Information Commonly Requested in Outpatient Treatment Request Forms,
By Type of Response MBHOs Only -
Total Examined – 7

Requested Information(2)	Categorical	Narrative	Both
Demographic/Administrative Information
Patient’s Name		7
Patient’s Date of Birth		6
Patient’s Social Security/Insurance ID number		6
Practitioner’s Name, Address, Phone		7
Practitioner’s License and/or ID number		6
Initial Authorization or Continuing	2	1
Length of Treatment/Start and End Dates		6
Diagnosis
DSM-IV Diagnosis Code	7
Current Global Assessment of Functioning (GAF)	6
Highest GAF in past year	5
Patient History
Previous MH/SA Treatment		2	1
History of Substance Abuse	2	3	1
Presenting Problems
Symptoms	5	1	1
Duration and Severity of Symptoms	4
Risk Assessment Suicide/Homicide	5		1
Current Substance Abuse	4	1	1
Family/Social Relationships	3	1	1
Job/School Performance	3	1	1
Obsessions/Compulsions	3		1
Treatment Information
Requested Procedures/Types of Services	5	1	1
Frequency/Duration of Treatment	2	5
Expected Treatment Outcomes	3	2
Member Notified/Concurs with Goals?	3
Medications
Current Medications	1	5
Dosage/Frequency	1	4
Compliance	2	2
Care Coordination
Communication with PCP	3	1
Patient Receiving Other Community Services	3	2

⁽¹⁾ Elements were included in table if they were listed in six of the eleven examples studied.
⁽²⁾ Elements were included in table if they were listed in six of the eleven examples studied.