Angel Hands Healthcare

ANGEL HANDS HEALTH CARE

Who Are We?

Angel Hands Healthcare is a Concierge Healthcare Practice. We provide mobile services to homes and facilities. We strive to provide convenient and high-quality care. Our goal is to treat the “WHOLE” you, mind & body

What Services Do We Provide?

Primary Care (Young Adults-Geriatrics)
Mental Health & Addiction
Psychiatric Rehabilitation Program/OMHC
Medical Marijuana Evaluations $100
Vaccinations & Flu Shots
COVID-19 Testing
Nutritional Counseling
IV Hydration
Laboratory Services/Phlebotomists

Form Selector

PRP Adult Referral PRP Minor Referral

PRP Adult Referral

ANGEL HANDS HEALTH CARE
PRP ADULT REFERRAL FORM

(410) 864-8181
6600 York Road, Suite 207, Baltimore, MD 21212

Client Name:
Client Phone:
Client Email:
Insurance:

DOB:
Address:

Policy #:

If uninsured, has the client applied for MA? Yes No

Name & Credentials of Referring Clinician:

Agency:

How long treating this individual? <1mo 2-3mos 4-6mos 7-12mos >1yr

Frequency of Treatment: 1x/week 1x/mo 2x/mo 1x/3mos 1x/6mos Inpatient

CATEGORY A DIAGNOSES

Schizophrenia F20.9
Schizophreniform Disorder F20.81
Schizoaffective Disorder Bipolar Type F25.0
Schizoaffective Disorder Depressed Type F25.1
Major Depressive Disorder Recurrent, w/ Psychotic Features F33.3
Bipolar I Disorder Current or Most Recent Manic, Severe w/Psychotic Features F31.2
Bipolar I Disorder Most Recent Depressed Severe, w/Psychotic Features F31.5
Other Specified Schizophrenia Spectrum & Other Psychotic Disorder F28
Unspecified Schizophrenia Spectrum & Other Psychotic Disorder F29
Delusional Disorder F22

CATEGORY B DIAGNOSES

Major Depressive Disorder Rec., Severe F33.2
Bipolar I Disorder, Current or Most Recent Manic Severe F31.3
Bipolar I Disorder Current or Most Recent Depressed Severe F31.4
Bipolar I Disorder Current or Most Recent Hypomanic F31.0
Bipolar I Disorder Current or Most Recent Hypomanic, Unspecified F31.9
Bipolar I Disorder Current or Most Recent Unspecified F31.9
Bipolar II Disorder F31.81
Borderline Personality Disorder F60.3
Other:

For additional Diagnosis please see the link: Mental Health Diagnosis

To qualify for PRP services, client must present with an impaired role functioning, check all that apply:

Choose a minimum of 3 in the following areas:

Employment – Inability to gain or maintain employment.
Activities of Daily Living – Challenges in performing necessary skills related to shopping, hygiene, cooking, etc.
Support System – Inability to establish or maintain relationships and connections that foster a sense of support.
Thought Impairment – Difficulty with focus, concentration, and retaining information. Needs prompting and/or reminders.
Self-Care – Inability or challenges to independently maintain personal hygiene, make appointments, manage money, etc.
Initiation – Inability to plan/organize, carry out goal-directed behavior, etc.
Community Living – Unable to live independently due to limited finances, inability to budget, manage money, etc.

Identify any other areas of need:

Legal Issues – Current issues related to the legal system.
Coping Skills – Ineffective tools to assist in handling difficult emotions and situations that may lead to unhealthy behaviors and/or substance use.
Symptom Management – Inability to identify and effectively cope with thoughts or behaviors related to mental illness.

Targeted Symptoms:

Anger
Anxiety
Auditory Hallucinations
Blunted Affect
Delusions
Depression

Grandiosity
Hopeless
Impulsive
Irritability
Lack of Insight
Mania

Mood Swings
Negative Symptoms
Obssessive Thoughts
Paranoia
Poor Concentration
Poor Stress Tolerance

Secondary Substance Use
Self-Injurious Behaviors
Social Isolation
Suicidality
Trauma
Visual Hallucinations

Narratives:

1. Does the participant have marked inability to establish or maintain competitive employment?
Yes No

Evidence of marked inability to establish or maintain competitive employment:

2. Does the participant have marked inability to perform instrumental activities of daily living (ie
shopping, meal preparation, laundry, basic housekeeping, medication management,
transportation, and money management)?
Yes No

Evidence of marked inability to perform instrumental activities of daily living (ie shopping, meal
preparation, laundry, basic housekeeping, medication management, transportation, and money
management):

3. Does the participant have marked inability to establish/maintain a personal support system?
Yes No

Evidence of marked inability to establish/maintain a personal support system:

4. Does the participant have deficiencies or concentration/persistence/pace leading to failure to
complete tasks?
Yes No

Evidence of deficiencies or concentration/persistence/pace leading to failure to complete tasks:

5. Is the participant unable to perform self-care (hygiene, grooming, nutrition, medical care,
safety)?
Yes No

6. Does the participant have marked deficiencies in self-direction, shown by inability to plan,
initiate, organize, and carry out goal directed activities?
Yes No

Evidence of marked deficiencies in self-direction, shown by inability to plan, initiate, organize, and
carry out goal directed activities:

7. Does the participant have marked inability to procure financial assistance to support community
living? Yes No

Duration of Impairments:

Signature of Licensed Referring Clinician:
(By signing, Licensed Clinician agrees with the above justification for PRP services.)

PRP Minor Referral

ANGEL HANDS HEALTH CARE
PRP MINOR REFERRAL FORM

(410) 864-8181
6600 York Road, Suite 207, Baltimore, MD 21212

Client Name:
Client Phone:
Client Email:
Insurance:

DOB:
Address:

Policy #:

If uninsured, has the client applied for MA? Yes No

Name & Credentials of Referring Clinician:

Agency:

How long treating this individual? <1mo 2-3mos 4-6mos 7-12mos >1yr

Frequency of Treatment: 1x/week 1x/mo 2x/mo 1x/3mos 1x/6mos Inpatient

CATEGORY A: must meet criteria and select C or D

C. The individual is currently enrolled in SSI or SSDI.
D. The individual demonstrates impaired role functioning for at least 2 years.

CATEGORY B: must meet criteria and select D

D. Individual demonstrates impaired role functioning for at least 2 vears.

For additional Diagnosis please see the link: Mental Health Diagnosis

To qualify for PRP services, client must present with an impaired role functioning, check all that apply:

Anger
Anxiety
Auditory Hallucinations
Blunted Affect
Delusions
Depression

Grandiosity
Hopeless
Impulsive
Irritability
Lack of Insight
Mania

Mood Swings
Negative Symptoms
Obssessive Thoughts
Paranoia
Poor Concentration
Poor Stress Tolerance

Secondary Substance Use
Self-Injurious Behaviors
Social Isolation
Suicidality
Trauma
Visual Hallucinations

Functional Limitations:

Within the past three months, the individual’s emotional disturbance has resulted in**

1. A clear, current threat to the youth’s ability to be maintained in their customary setting?
Yes No

Evidence of a clear, current threat to the youth’s ability to be maintained in their customary setting:

2. An emerging risk to the safety of the youth or others?
Yes No

Evidence of an emerging risk to the safety of the youth or others:

3. Significant psychological or social impairment causing serious problems with peer relationships
and/or family members?
Yes No

Evidence of significant psychological or social impairment causing serious problems with peer
relationships and/or family members:

4. What evidence exists to show that the current intensity of outpatient treatment for this individual is
insufficient to reduce the youth’s symptoms and functional behavioral impairments resulting from
mental illness?

5. How will PRP serve to help this youth get to age appropriate development, more independent
functioning, and independent living skills?

Is a documented crisis response plan in response in progress or completed? Yes No

Has an individual treatment plan/individual rehabilitation plan been completed? Yes No

Other Referral Information

1. Is the participant eligible for fully funded Developmental Disabilities Administration services?
Yes No

2. Have family or peer support been successful in supporting this youth?
Yes No

3. Is the primary reason for the participants impairment due to an organic process or syndrome,
intellectual disability, a neurodevelopmental disorder or neurocognitive disorder?
Yes No

4. Has the participant been judged to be in enough behavioral control to be safe in a PRP program
and benefit from the rehab provided?
Yes No

5. Will the participants' level of cognitive impairment, current mental status or developmental level
negatively impact their ability to benefit from PRP?
Yes No

Signature of Licensed Referring Clinician:
(By signing, Licensed Clinician agrees with the above justification for PRP services.)

Contact Us

Give Us A Call At (410) 864-8181 Ext. 2

✉ Email Us At angelhandshealthcare@outlook.com

If you have any questions or inquiries pertaining to billing, please contact our billing department, Advanced Medical Services!

Advanced Medical Services Phone Number: (410) 663-4036

Advanced Medical Services Fax Number: (443) 378-7288