MEMORANDUM OF UNDERSTANDING BETWEEN THE ...

. 90804/90805/90806 Individual therapy (staff or MD) at least 3 monthsc. 90805/90862 Medication management and monitoring (if appropriate)d. 90853 - Aftercare Group therapy (staff) weekly every Tuesday for at least 6 monthse. 90853 - Intensive OPT Psycho educational Modules (twice a week for 6 weeks)f. 90804/90805/90806 - Crisis intervention (by staff and/or MD)g. 90889 - Preparation of Reports (by staff and MD)h. 90804/90805/90806 - Brief Family or Marital counseling2, AF provider completes referral request and faxes referral and results of the physical examination,laboratory testing and EKG (if required) with original referral to Mental Health Clinic to the attention of“Lead Clerk” at636-3079. Referral request will contain the following demographic data and clinicalinformation needed to load patient into CPRS:a. Patient’s name, address and phone numberb. Patient’s social security number (Include sponsor’s social security number if dependent)c. Patient’s branch of service and unit assignedd. Patient’s date of birthe. Provider name and telephone numberf. Reason for consultationg. Desired time frame for consultation3. Pre-Assessment to be completed by the referral site to include the following:a. Indications for consultationb. Allergiesc. Substance abuse/Addictions Historyd. Current psychiatric issuese. Mental Status Exam1’. Suicide Risk Assessmentg. Past psychiatric historyh. Legal issues (convictions, pending)i. Medical issuesj. Medications other then listed this VA’s medical record (current community prescriptions andOTC medications)k. Current or recent pain issues1. Functional Assessment (Social (residence, income/month, support system)m. Assessmentn. Diagnostic Impressionso. Treatment Planp. Patient Educationq. Addiction Severity Index, if indicated4. VASNHS Lead Clerk will ensure the information is given and inputted by VASNHS Enrollment Section intoVistA as a non-veteran sharing agreement patient. After the data is entered into VistA, VASNHS Lead Clerkwill give the consult to the VASNHS Mental Health Addictions Provider.5. VASNHS Mental Health Addictions Provider enters the consult into CPRS based on information providedby AF.6. VASNHS Mental Health Clerks will contact the patient to schedule appointment.7. VASNHS Addictions Counselor will maintain a monthly listing of patients referred and treatment rendered.