Fillable Printable Bhs Policy Form 106.2
Fillable Printable Bhs Policy Form 106.2
Bhs Policy Form 106.2
Page 1
Policy Form 106.2, SMI Determination Verification
Effective: 09/29/2015
Use
This for m is to be completed for individuals who have previously been determined to ha ve
SMI, but whose determination paperwork is outdated (10+ years old), missing, or otherwise
incomplete. This is NOT for use with any po pulatio n other than thos e currently determined
SMI by the appropriate authority.
Purpose
The purpose of this form is to allow the T/RBHA and its contra c te d providers to submit
updated diagnostic and functional status for individuals who have already been deter mined to
have SMI in the Arizona public health system.
Instructions
This form is to be completed by a licensed psychiatrist, psyc hologist, or nurse p r a c titioner. By
signing this fo rm, the provider a ttests that, to t he best of their knowledge, the individual has
been determined to have SMI. The qualified person must check off t he current
diagnosis/diagnoses, check off the area/areas of impairment, check off the A or B status, an d
complete the signature line at the botto m. The form must be forwarded to the T/RBHA for
review and signature by appropriate T/RBHA staff and included in the individual’s Medical
Record. (For more information see DBHS Polic y 106 , Serious Mental Ill ness Deter minati on).
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Policy Form 106.2, SMI Determination Verification
Effective: 09/29/2015
Member Name:
To be co mpleted by a licensed psychiatrist, psychologist, or nurse practitioner:
1. Qualifying Diagnosis: (Select the person’s principal diagnosis(es) supported by available information.)
Psychotic Disorders:
F20.0, F20.1, F20.2, F20.3, F20.5, F20.9, F21, F22, F25.0, F25.1, F25.8, F25.9,
F28, F29
Bipolar Disorders:
F31.0, F31.1, F31.10, F31.11, F31.12, F31.13, F31.2, F31.30, F31.31, F31.32, F31.4,
F31.5, F31.60, F31.61, F31.62, F31.63, F31.64, F31.70, F31.71, F31.72, F31.73,
F31.74, F31.75, F31.76, F31.77, F31.78, F31.81, F31.89, F31.9, F34.0
Obsessive Compulsive Disorder:
F42
Depressive Disorder:
F32.0, F32.1, F32.2, F32.3, F32.4, F32.5, F32.8, F32.9, F33.0, F33.1, F33.2,
F33.3, F33.4, F33.40, F33.41, F33.42, F33.9, F34.1
Other Mood Disorders:
F39
Post-Traumatic Stress Disorder:
F43.10, F43.11, F43.12
Dissociative Disorder:
F44.81
Obsessive Compul si ve Disorde r and Var i ants:
F42
Anxiety Disorders:
F40.00, F40.01, F40.02, F41.0, F41.1, F41.8, F41.9
Personality Disorders:
F60.0, F60.1, F60.3, F60.4, F60.5, F60.6, F60.7, F60.81, F60.89, F60.9
2. Functional Criteria: As a result of the above diagnosis, the person exhibits any item listed under 2(a), (b), and/or (c) for most
of the past twelve months or f or most of the past six mo nths with an expected c ontinued durat ion of at least six months:
2(a) Inability to live in a n independent or family setting without supervision (Self Care/Basic Needs) – The person’s
capacity to live independently o r in a family setting, including the capacity to provide or arrange for needs such as
food, clothing, shelter and medical care.
2(b) A risk of serious harm to self or others (Social/ Legal and/or Feeling/Affect/Mood) - The extent and ease with
which the person is able to maintain conduct within the limit s p rescribed by law, rules and socia l expectations, and/or
the extent to which the person ’s emotional life i s well modula te d or out of co ntrol.
2(c) Dysfunction in Role Performance – Person’s capacity to perform the present major role function in society --
school, work, parenting or other developmentally appropriate responsibility.
3. Risk of Deterioration:
3) Ris k of Deterioration: The person does not currently meet any one of the above functional criteria 2(a) through
2(c) but may be expected to deteriorate to such a level wi thout treat ment.
SERIOUS MENTAL ILLNESS (SMI) DETERMINATION VERIFICATION
(For indiv i duals who have previously bee n de termine d SM I and require upda ted det e rmination documentation)
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Policy Form 106.2, SMI Determination Verification
Effective: 09/29/2015
FINAL SMI DETERMINATION
SMI-A – fun ctional crit e ria 2a or 2b .
SMI-B – functional criteria 2c or 3.
/
/
Assessor’s Name (pr int) / Signature
Credentials/Position
Date
/
/
T/RBHA Reviewer Na me (pr int) / Signa ture
Credentials/Position
Date
