Appendix F
Personal Health Information Requested by Local and National MCOS

[Main Page of Report | Contents of Report]

Patient Health Information
Commonly Requested in Outpatient Treatment Request Forms,
By Type of Response Local Managed Care Firms Only -
Total Examined – 6

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

Patient Health Information Commonly Requested in Outpatient Treatment Request Forms,
By Type of Response National Managed Care Firms Only -
Total Examined – 5

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

⁽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.