Beacon Health Strategies EAP Submission Provider Name Provider's Email Patient Name Patient URL (Copy the web address from internet browser) Patient Authorization # Did you send to a copy of the authorization form to MCMSouth? Yes No Beacon CASE CLOSING: Beacon Assessed Problem: Check 1 box only Alcohol Drugs Mixed Alcohol/ Drug Abuse Anxiety Depression Eating Disorder Hyperactivity / Learning Impulse control Thought disorder Child care Adult / elder care Family problems Financial problems Grief / Loss Job/ Occupational Legal Marital/ Relationship Situational / Adjustment Medical If your patient is using Beacon Please complete this section (These sections are directly from Beacon EAP form) 1) Beacon Risk and Functional Assessment: Member's risk to self: Case Opening 0 (Zero) 1 (One) 2 (Two) 3 (Three) These sections are directly from Beacon EAP form (Indicate impairment level at case opening and closing.) 1) Beacon Risk and Functional Assessment: Member's risk to self: Case Closing 0 (Zero) 1 (One) 2 (Two) 3 (Three) These sections are directly from Beacon EAP form (Indicate impairment level at case opening and closing.) 2) Beacon Risk and Functional Assessment: Member's risk to others: Case Opening 0 (Zero) 1 (One) 2 (Two) 3 (Three) These sections are directly from Beacon EAP form (Indicate impairment level at case opening and closing.) 2) Beacon Risk and Functional Assessment: Member's risk to others: Case Closing 0 (Zero) 1 (One) 2 (Two) 3 (Three) These sections are directly from Beacon EAP form (Indicate impairment level at case opening and closing.) 3) Beacon Risk and Functional Assessment: Mood Disturbances (depression or mania): Case Opening 0 (Zero) 1 (One) 2 (Two) 3 (Three) These sections are directly from Beacon EAP form (Indicate impairment level at case opening and closing.) 3) Beacon Risk and Functional Assessment: Mood Disturbances (depression or mania): Case Closing 0 (Zero) 1 (One) 2 (Two) 3 (Three) These sections are directly from Beacon EAP form (Indicate impairment level at case opening and closing.) 4) Beacon Risk and Functional Assessment: Anxiety: Case Opening 0 (Zero) 1 (One) 2 (Two) 3 (Three) These sections are directly from Beacon EAP form (Indicate impairment level at case opening and closing.) 4) Beacon Risk and Functional Assessment: Anxiety: Case Closing 0 (Zero) 1 (One) 2 (Two) 3 (Three) These sections are directly from Beacon EAP form (Indicate impairment level at case opening and closing.) 5) Beacon Risk and Functional Assessment: Thinking/ Cognition/ Memory/ Concentration: Case Opening 0 (Zero) 1 (One) 2 (Two) 3 (Three) These sections are directly from Beacon EAP form (Indicate impairment level at case opening and closing.) 5) Beacon Risk and Functional Assessment: Thinking/ Cognition/ Memory/ Concentration: Case Closing 0 (Zero) 1 (One) 2 (Two) 3 (Three) These sections are directly from Beacon EAP form (Indicate impairment level at case opening and closing.) 6) Beacon Risk and Functional Assessment: Impulse/ Reckless/ Aggressive Behavior: Case Opening 0 (Zero) 1 (One) 2 (Two) 3 (Three) These sections are directly from Beacon EAP form (Indicate impairment level at case opening and closing.) 6) Beacon Risk and Functional Assessment: Impulse/ Reckless/ Aggressive Behavior: Case Closing 0 (Zero) 1 (One) 2 (Two) 3 (Three) These sections are directly from Beacon EAP form (Indicate impairment level at case opening and closing.) 7) Beacon Risk and Functional Assessment: Activities of Daily Living Problems: Case Opening 0 (Zero) 1 (One) 2 (Two) 3 (Three) These sections are directly from Beacon EAP form (Indicate impairment level at case opening and closing.) 7) Beacon Risk and Functional Assessment: Activities of Daily Living Problems: Case Closing 0 (Zero) 1 (One) 2 (Two) 3 (Three) These sections are directly from Beacon EAP form (Indicate impairment level at case opening and closing.) 8) Beacon Risk and Functional Assessment: Medical/ Physical Condition: Case Opening 0 (Zero) 1 (One) 2 (Two) 3 (Three) These sections are directly from Beacon EAP form (Indicate impairment level at case opening and closing.) 8) Beacon Risk and Functional Assessment: Medical/ Physical Condition: Case Closing 0 (Zero) 1 (One) 2 (Two) 3 (Three) These sections are directly from Beacon EAP form (Indicate impairment level at case opening and closing.) 9) Beacon Risk and Functional Assessment: Substance Abuse/ Dependence: Case Opening 0 (Zero) 1 (One) 2 (Two) 3 (Three) These sections are directly from Beacon EAP form (Indicate impairment level at case opening and closing.) 9) Beacon Risk and Functional Assessment: Substance Abuse/ Dependence: Case Closing 0 (Zero) 1 (One) 2 (Two) 3 (Three) These sections are directly from Beacon EAP form (Indicate impairment level at case opening and closing.) 10) Beacon Risk and Functional Assessment: Job/ School Performance: Case Opening 0 (Zero) 1 (One) 2 (Two) 3 (Three) These sections are directly from Beacon EAP form (Indicate impairment level at case opening and closing.) 10) Beacon Risk and Functional Assessment: Job/ School Performance: Case Closing 0 (Zero) 1 (One) 2 (Two) 3 (Three) These sections are directly from Beacon EAP form (Indicate impairment level at case opening and closing.) 11) Beacon Risk and Functional Assessment: Social Functioning/ Relationship/ Marital/ Family: Case Opening 0 (Zero) 1 (One) 2 (Two) 3 (Three) These sections are directly from Beacon EAP form (Indicate impairment level at case opening and closing.) 11) Beacon Risk and Functional Assessment: Social Functioning/ Relationship/ Marital/ Family: Case Closing 0 (Zero) 1 (One) 2 (Two) 3 (Three) These sections are directly from Beacon EAP form (Indicate impairment level at case opening and closing.) Beacon CASE CLOSING: Beacon Problem Status at Closing: Check 1 box only Resolved Partially Resolved Getting Worse No Challenge Not Applicable If your patient is using Beacon Please complete this section (These sections are directly from Beacon EAP form) Beacon CASE CLOSING: Beacon Disposition: Check 1 box only Face-to-face assessment/ no referral Face-to-face assessment/ referral accepted Assessment/ referral declined Did not keep initial appt Withdrew before completion If your patient is using Beacon Please complete this section (These sections are directly from Beacon EAP form) Sessions Date(s) (Please list if not shown in software) The EAP sessions to be billed Is this the last EAP session for patient? Yes No Share this:TweetShare on TumblrPocketPrintWhatsAppMoreReddit
