Medical Necessity Note
REQUIRED FORM:
This form is required in client file for Medi-Cal providers only
WHEN:
Completed within thirty days of admission
COMPLETED BY:
Authorized agency representative and reviewed and established by Medical Director
REQUIRED ELEMENTS:
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Client Name: Complete with client’s full name.
Client ID#: Complete the client ID number as determined by agency guidelines.
Primary Counselor: Complete name of client’s primary counselor.
Date of Service: The date evaluation was conducted with client by counselor.
Service Code: Select the appropriate service code (e.g. 2-Individual Counseling-Intake, 3Individual Counseling-Planning, 4-Crisis Intervention.
Medical Necessity Documentation: Establish and document client’s medical necessity from
criteria in the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) or
newest published version.
Diagnostic Impression: This is the initial diagnostic formulation based on the client’s
presentation. Document all relevant symptoms, impairments, timeframes, etc. that lead to this
impression. The Medical Director will make the final diagnosis.
Counselor Signature and Printed Name: Complete name of counselor who developed the
diagnostic impression.
Date: The date the diagnostic impression note was documented by the counselor.
Medical Doctor Date and Signature: Medical Doctor reviews form to determine diagnosis.
Medical Doctor indicates that services are medically necessary and must print and sign name
and date.
NOTES:
Must be reviewed by QAR for an initial, stay, extension, and discharge.
BHS/ADS INSTRUCTION, F409
Page 1 of 1
March 2016