Psychiatric Rehabilitation Program – Adults (PRP-A) Referral Form Step 1 of 5 20% PRP AdultDate(Required) Month Day Year Name(Required) First Last Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Required)Social Security # Birth of Date(Required) Month Day Year Age(Required) Medicaid # (if known) Marital status(Required) Single Divorced Widowed Significant other Employed(Required) Yes No Has this individual received PRP services before?(Required) Yes No Program Name: Dates of service (if known) Month Day Year PRP Adult PRP AdultCurrent Diagnosis(Required) 296.31 Major depressive disorder, Recurrent episode, Mild 296.32 Major depressive disorder, Recurrent episode, Moderate 296.33 Major depressive disorder, Recurrent episode, Severe 296.51 Bipolar I disorder, Current or most recent episode depressed, Mild 296.52 Bipolar I disorder, Current or most recent episode depressed, Moderate 296.53 Bipolar I disorder, Current or most recent episode depressed, Severe 296.41 Bipolar I disorder, Current or most recent episode manic, Mild 296.42 Bipolar I disorder, Current or most recent episode manic, Moderate 296.43 Bipolar I disorder, Current or most recent episode manic, Severe 295.90 Schizophrenia 295.70 Schizoaffective disorder, Bipolar type 295.70 Schizoaffective disorder, Depressive type PRP Adult PRP AdultHas this individual been impaired for at least 2 years in any of the following categories? Please check at least 3 of the following categories if applicable(Required) Marked inability to establish or maintain independent competitive employment: characterized by an established pattern of unemployment, underemployment, or sporadic employment that is primarily attributable to a diagnosed Page 16 of 47 BH2564_01/2020 serious mental illness, which requires intervention by the behavioral health system beyond what is available to the individual from by mainstream workforce development, educational, faith-based, community or social service organizations. This does not include limitations due to factors such as geographic location, poverty, lack of education, availability of transportation, or loss of driver’s license due to legal problems. Marked inability to perform instrumental activities of daily living (shopping, meal preparation, laundry, basic housekeeping, medication management, transportation, and money management) that is primarily attributable to a diagnosed serious mental illness, which requires intervention by the behavioral health system beyond what is available to the individual from by mainstream workforce development, educational, faith-based, community or social service organizations. This does not include limitations due to factors such as geographic location, poverty, lack of education, availability of transportation, or loss of driver’s license due to legal problems. Marked inability to establish or maintain a personal support system, characterized by social withdrawal or isolation, interpersonal conflict, or social behavior (other than criminal behavior) that is not easily tolerated in the community and primarily attributable to a diagnosed serious mental illness, and which requires intervention by the behavioral health system beyond what is available to the individual from by mainstream workforce development, educational, faith-based, community or social service organizations. This does not include limitations due to factors such as geographic location, poverty, lack of education, availability of transportation, or loss of driver’s license due to legal problems Marked or frequent deficiencies of concentration, persistence or pace that is primarily attributable to a serious mental illness resulting in a failure to complete in a timely manner tasks commonly found in work, school, or home settings, which requires intervention by the behavioral health system beyond what is available to the individual from by mainstream workforce development, educational, faith-based, community or social service organizations Marked inability to perform or maintain self-care (hygiene, grooming, nutrition, medical care, personal safety) that is primarily attributable to a serious mental illness, and which requires intervention by the behavioral health system beyond what can be reasonably provided by mainstream workforce development, educational, faith-based, community or social service organizations Proper interaction with peers Marked deficiencies in self-direction, characterized by an inability to independently plan, initiate, organize, and carry out goal-directed activities that is primarily attributable to a serious mental illness, and which requires intervention by the behavioral health system beyond what can be reasonably provided by mainstream workforce development, educational, faith-based, community or social service organizations. Marked inability to procure financial assistance to support community living, which inability is primarily attributable to a serious mental illness, and which requires intervention by the behavioral health system beyond what can be reasonably provided by mainstream workforce development, educational, faith-based, community or social service organizations. This does not include limitations due to factors such as geographic location, poverty, lack of education, availability of transportation, or loss of driver’s license due to legal problems. PRP Adult PRP AdultConsent(Required) I understand that I am making a referral for PRP services and said services must be authorized by Optum Md before any PRP services may begin.Referred By (Name & credentials)(Required) Date(Required) Month Day Year Name of Facility or Program(Required) Program /Facility Address Program /Facility Phone(Required)Program /Facility Email PRP Adult Referral Authorizations(Required) I agree to the referral authorization termsReferral Authorizations I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits to Restoration Behavioral Health Systems. I authorize payment of medical benefits to Restoration Behavioral Health Systems. I also understand that payment of is my responsibility and Restoration Behavioral Health Systems has the right to use any means necessary to collect fees to include submission of my name and other information to a collection agency for the purposes of fee collection. I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits to Restoration Behavioral Health Systems. I authorize payment of medical benefits to Restoration Behavioral Health Systems. I also understand that payment of is my responsibility and Restoration Behavioral Health Systems has the right to use any means necessary to collect fees to include submission of my name and other information to a collection agency for the purposes of fee collection. I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits to Restoration Behavioral Health Systems. I authorize payment of medical benefits to Restoration Behavioral Health Systems. I also understand that payment of is my responsibility and Restoration Behavioral Health Systems has the right to use any means necessary to collect fees to include submission of my name and other information to a collection agency for the purposes of fee collection. Typing my name below serves as my digital signature.Digital Signature(Required) CAPTCHA
