Initial Treatment Plan (Medication Management)

Print Form IDAHO CRIME VICTIMS COMPENSATION PROGRAM Initial Treatment Plan Medication Management CV#: Parent/Guardian: Physician's Name: Name of coordinating Therapist: Name of Facility:____________________________ Are you a provider under the following programs? Medicaid Medicare Blue Cross Indian Health Services Patient's Name: Tax I.D. #: TriCare Blue Shield Other Indicate what sources of payment are available to the patient: Date treatment began: Number of sessions to date: Are you providing individual psychotherapy to this patient? Yes No 1. Please describe the presenting symptoms or conditions for which the patient is seeking treatment. 2. Does the patient have a history of previous health conditions that have required medication? Yes No If so, indicate approximate dates of treatment, reasons for the medication, and results of the treatment. 3. Please provide a brief description of the crime as related to you, including the source of the information (i.e. patient, parent or other). 4. Please describe any pre-existing conditions that are present that require medication to manage and to what extent these conditions were exacerbated by the crime. 5. Please list any medications that the patient was taking at the time of your assessment. Medication Reason for Medication Dosage Duration C:\formdocuments\Initial Treatment Plan ­ Med Mgmt (1/05) American LegalNet, Inc. www.FormsWorkFlow.com 6. Indicate percentage of medication management you are providing for any pre-existing or non-crime related conditions. % 7. Describe the symptoms/conditions you are treating that are a direct result of the crime. 8. Indicate percentage of medication management you are providing for any conditions that are a direct result of the crime. % (Percentages from #6 and #8 should equal 100%) 9. Please indicate how often you will see this patient. per 10. List below the medications you are prescribing and what symptoms/conditions they are treating, and whether that prescription is for conditions that are a direct result of the crime. Medication Symptoms/Conditions being treated Crime Related Percentage of Rx 11. I certify that the information provided in this treatment plan is true and accurate. I acknowledge that if the alleged offender is convicted, the Program will request the criminal court to order the alleged offender to pay restitution to reimburse the Program for expenses paid on behalf of the patient. I further acknowledge that this document may be submitted as evidence and that I may be called to testify regarding the treatment outlined in this plan. Signature of Physician Date C:\formdocuments\Initial Treatment Plan ­ Med Mgmt (1/05) American LegalNet, Inc. www.FormsWorkFlow.com