Mental health professionals treating an Ohio workers' compensation claim can use this one-page summary to share treatment information without releasing psychotherapy notes. It reports the allowed DSM conditions being treated, session length and modalities, symptoms, prognosis, progress and functional status. BWC and managed care organizations use it to manage the medical side of the claim, including whether care should continue.
The treating mental health professional, such as a psychologist, psychiatrist, licensed counselor or social worker, completes and signs the whole form with an NPI. The injured worker does not complete any part.
Download the current version from the source each time; forms change without notice.
Mental Health Notes Summary (Non-Psychotherapy Note)
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No. The title calls it a non-psychotherapy note. It summarizes treatment dates, frequency, session length, modalities, medication monitoring, symptoms, prognosis, progress, goals and functional status, so the MCO can manage the claim without receiving the clinician's psychotherapy notes.
For a state-fund claim, fax or mail it to the managed care organization assigned to the claim, which the injured worker or employer can identify. If the injured worker is employed by a self-insuring employer, the instructions say to mail or fax the completed form to that employer.