Encounter type
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Phone call w/ PCP (PCP initiated)
Phone call w/ PCP (CHAMP initiated)
Email from PCP (PCP initiated)
Call not appropriate for CHAMP
Online form
Date contact initiated
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Today M-D-Y
Time contact initiated
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Now H:M
Aaron Blair Abigail Etters Adam Metzler Adam Will Adnan Arseven Aimee Black Aimee Deiwert Aimie Greulach Alan Maugherman Alexander Kemery Alexandria Ceranske Alexis Huckleberry Alexis Shuler Alfredo LOPEZ YUNEZ Alice Hartman Alisa Felke Alissa Conklin Allyson DiMagno Alyssa Hatfield Alyssa Hoopingarner Alyssa Ingle Amanda Carlock Amanda McKinney Amanda Williams Amber Burleson Amber Anderson Amber Burns Amita Reed Amy Guzman Amy Han Amy Jackson Amy Jo King Ana Perry Ana Rodriguez Sandoval Andrew Lasley Andrew Van Velsor Angela Lyttle Anita Joshi Anita Turk Anna Grady Anna Pendrey Anna Pendrey Anne Brookhyser Anne Campbell Anne Campbell Annella Dixon Annette Edgell Anthony Iwuagwu Antonio Carrelli Apryl Brown Apryl Brown APRYL BROWN Apryl Brown Ashleigh Saulmon Ashley Burks Ashley Berish Ashley Mundil Ashley Rollins Ashley Smith Ashley Stowe Ashley Williams Ashley Williams Ashley Williamson Asima Rashid Aubrey Brinneman Hawk Audra Moor Audrey Wagaman Autumn Burkman B. Beth McKay Beatrice Soderholm Belinda Gamble Berta Hogan Bethany Schultz Betsy Rosiek Blair Wagoner Brandi Tolman Bree Simmons Brenda DeArmond Brian Johnson Brogan Hayden Brooke Aljandali Brooke Hansen Brooke Schaefer Bryrony Homan Caitlin Bernard Callie Bushong Carrie Bonsack Carrie Rouse Casey Cummins Cassandra Selby Cassandra Smith Catherine Baugher Catherine Chung Catherine Przybyla Cathleen Mok Cathy Bryant Ceciley Casselman Chad Minier Chanda Boyden-Deidrick Charles Dinwiddle Chelsea Worstall Chimere Nnaji Chris Hamm Chris Iorio Chris Mernitz Chris Mernitz Chris Stoner Christa Lewis Christine Pankau Christyna Kiesel Cindy Zimmerman Cipriana Ortega Claudet Smith Corie Hess Cortney Riley Cory matters Cory Newmann Cristina Emch Cristina Perez Cynthia Bodkin Daniel Lopiccolo Daniel Pino Danielle Tat Danielle Tat Daphne Pontius Darla Berry Darla Berry Dave Wright David Amrhein David Blackwell Davinia Givens Davinia Givens Debbie Equihua Deborah Carpenter Debra Garner Delaney Baumann Delaney Kaiser Derek Voss Derrick Williams Diana Summanwar Dominique Harte Dominique Nettles Elisabeth Prosser Elisabeth Barahona Elizabeth Dieckmann Elizabette Johnson Ellen Turner Emilee Delbridge Emily Ferguson Emily Hart Emma Nordstrom Erica Aukerman Erika Brandenstein Erin Cleary Erin Hendricks Erin McDonald Erin Mooney Erin Tingler Erin Weah Evan Kreutzer Felipe Perez Filomeno Fiel Frank Lloyd Gabriela Romo Gage Williamson Gerardo Diaz Giavonne Rondo Glenda Westmoreland Grace Greist Grace Greist Grant Hammons Gregory Gramelspacher Gregory Todd Greta Clement Guadalupe Kelle Hannah Drazenovich Heather Hare Heidi Harris-Bromund Heidi Harris-Bromund Heidi Lakanen Hilda Torres Urista Jacinta Langley Jacqueline Nti Jadyn Mangen Jaekyung Cho Jani Reisinger Jaron Stiers Jasmine Vayalil Jasmine Porter Jasmine Porter Jean Beischel JEFF ROTHENBERG Jefferson Jose Jenel Charlton Jennifer Amador Jennifer Behrens Jennifer Walsh Jennifer Weida Jennifer Brown Jennifer Bunch Jennifer Hartwell Jennifer Ramey Jennifer Woodard Jerry Fletcher Jessica Lipp Jessica Brown Jessica Lipp Jessica Ranes Jessica Swenberg JIll PRickel Jim Cohen Jo Anna Curless Joanna Campodonico Joanna Campodonico Joanne Delisle Joel Gerig Johari Miller John Adame Jon Salisbury Joni Whetzel Joseph Goodman Joseph Vormohr Joshua Leichty Juan Carlos Venis Judith Kennedy Julia Krieger Julia Loubeau Julia vanArragon Julian LaBelle Julie Schnieders Julio Beas Nino de Guzman Kaleb Lane Kami Sherwood Kapil Mehta Kara Hawk Karen Newcomer Karenrose Martinez Kari Sears Karin Comastri Kasie Power Katharine Callaghan Katherine Gehlhausen Kathleen Unroe Kathryn Feeney Kathryn Lannert Kathy James Katie Carson Katie Kauffman Katie Schramm Kelly Brinkley Kelsea LeRose Ken Coats Kenelle Freeman Kevin Luksus Keyna Martinez Kimberly Harter Kimberly Keever Kimberly Smith Kimbre Zahn Kirsten Metz Krista Brucker Kristen Primeau Kristin Grant Kristin Perrone Kristine Miller Kristyn Tekulve Krystle Roberts Kyla Neely Kyle Langfitt Lacey Carroll Lara Lahr Laura Mabry Laurel Fick Leah Garrett Leah Richardson Leann Sharp LeeAnne Nazer Lena Parr Leslie Littrell Leslie Phillips Lian Hnin Lindsay Coda Lindsay Gregg Lindsay Jobe Lindsey Porta Lindsey Anderson Lisa Hodge Lisa Mims Litoia Kendrick Lloyd Lewis Lora Alvey Perry Madeline Briere Magali Chumbiauca Maham Nadeem Mandy Williams Marci Jefferson Marcy Aldrich Margaret Loewen Margaret Zelasko Maria Faget Mariann Frigo Marla Evans Mary Abernathy mary christy Matea Rippe Meaghan Merriman Meaghan Mobley Megan Barnett Megan Boruff Melanie Schreiner Melanie Schreiner Melissa Holderread Melissa Barker Melissa Johnson Melissa Mueller Melissa Reisinger Melissa Terry Michael Boothe Michael Danh Michael Massaro Micheala Taylor Michelle Solik Michelle Miller Good Michelle Wright Milissa Eley Milissa Eley Minakshee Mohanty Mindy Enyart Miranda Schneider MNJUZI NYIRENDA Molly Reitinger Monica Murillo Mrnual Patel Mureena Turnquest Wells Nadine Horn Nancy Torres Natalie Gilbert Natalie Stafford Nicholas Berlon Nichole Hutchinson Nicole Boersma Obafemi Akinsanya Olivia Nirmalasari Olivila Neese Oluwatobiloba Adenuga Otito Aronu Pamela Thornton Pamela Thornton Paul Mingo Pearl Quartey-Kumapley Peter Baenziger Phillip Estep Phillip Scott Poonam Paruchuri Rachel Demerly Rachel Emery Rachel Russel Rachel Woods Rachel Yoder Rajalakshmi Venkatesh Shantharam Rashed Dahabrah Rea Sebata Rebecca Cronin Rebecca Hendricks Rebekah Ferrell Rebekah Seda Renae Atkins Robert Fawcett Robert Fick Robyn Wieten Ruth Human Ryan Reinbeau Sabrina Silver Sabrina White Samantha Kay Samantha Loeser Sanjana Prasad Sarah Wagner Sarah Bosslet Sarah Chapman Sarah Hartman Sarah Turner Savanna Bruski Shae Jansen Sharlotte Brown Sharmilee Thota Sharon Clevenger Sharon Singleton Sharron Grannis Shelagh Fraser Sherry Lewis Sofia Ligard Sophia Addy Spencer Kuper Spencer Medcalf Stacy Griffin Stacy Shultz Stephanie Lothamer Stephen Dewey Stephen Knaus Susan Bilbrey Susan Bishop Susan Schnerre Susana Diaz Susana Lagunas Suzanne Johannigman Suzanne Martini Sydney Maloy Tamara Iorio Tashera Perry Terence Grogan Teresa Lovins Teresea Higham Tessa Thorstenson Theresa Woods Thomas Duncan Tina Brickert Tobin Eicher Tom Freije Tucker Balam Valerie Topper Valerie Topper Victoria Floyd Victoria Foerster Victoria Osayi Vida McGhee-Lewis Vincent True Whitney Correll Whitney Fraiz William Berry William Heisel Yadira Santiago Banuelos Yanira Castellanos Yashobha Voss Zachary Dobbin Zachary Patton
Caller name
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(First Last)
Credential
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MD DO PA NP MSN RN BN PhD LCSW MSW Other
Best call back number
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Secondary callback number
Email
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Provider Practice
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Provider County
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Adams Allen Bartholomew Benton Blackford Boone Brown Carroll Cass Clark Clay Clinton Crawford Daviess Dearborn Decatur De Kalb Delaware Dubois Elkhart Fayette Floyd Fountain Franklin Fulton Gibson Grant Greene Hamilton Hancock Harrison Hendricks Henry Howard Huntington Jackson Jasper Jay Jefferson Jennings Johnson Knox Kosciusko La Porte Lagrange Lake Lawrence Madison Marion Marshall Martin Miami Monroe Montgomery Morgan Newton Noble Ohio Orange Owen Parke Perry Pike Porter Posey Pulaski Putnam Randolph Ripley Rush St. Joseph Scott Shelby Spencer Starke Steuben Sullivan Switzerland Tippecanoe Tipton Union Vanderburgh Vermillion Vigo Wabash Warren Warrick Washington Wayne Wells White Whitley UNKNOWN
Requested time for call back
*Please allow up to 60 minutes if you have selected "As soon as form is received"*
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As soon as form is received
Whenever possible during business day
Specific time
Specific time requested
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Is this consultation regarding an adult OR perinatal psychiatry question?
Please select perinatal if the patient is pregnant or up to 1 year postpartum.
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Adult Psychiatry
Perinatal
CHAMP services needed
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Referral
Psychiatry consult
Both Referral and psychiatry Consult
Is this a general question not pertaining to a specific patient? If yes, please proceed to the Reason for Contact section.
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Yes
No
Is this a first time consultation call for this patient or a follow up consultation call about a specific patient?
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first time consult
follow up
(Last, First)
Today M-D-Y
View equation
Calculate Age
Cis-male Cis-female Trans-female (male at birth) Trans-male (female at birth) Non-binary gender Intersex
Unknown None 6 Degree Health Aetna Aetna Medicare Allied-Cigna Allwell Medicare Advantage PPO/HMO) Ambetter(MHS)Cenpatico Amish Anthem Blue Access PPO Anthem Blue Cross Blue Shield Anthem (DXP) Anthem (EJM) Anthem (EJN) Amthem (FXZ) Anthem (GBH) Anthem (LCB) Anthem (NEI) Anthem (OEHOE) Anthem(PEX) GE Electric Anthem ( XOF) Anthem (SYY) Anthem (YRH)(Medicaid) Anthem(YRP) Anthem HIP (YRK) Anthem HIP(YK) Anthem Hoosier Healthwise (YRH) Anthem Medicaid Anthem Medicaid -St Francis Anthem Medicare Advantage HMO Anthem Medicare Advantage PPO Anthem Marketplace (XPA,XPB,XPC,XPR,XPW) Anthem Pathway (XPD, XPE,XPH,XPU,XPV) Anthem PPO Ascension/ Smarthealth/Anthem BCBS Beacon Caresource Marketplace -(Just4Me) Caresource Medicaid Healthy Indiana Plan(HIP) Caresource Medicaid Hoosier Healthwise(HHW) Caresource Medicaid only Cenpatico(MHS) Medicaid Centrene(MHS) Medicaid Chandler Group Christian Healthcare cards Christian Ministries Co-OP Chrysler -Anthem BCBS Cigna Cigna- Sagamore- employee plans Cigna Behavioral Health Cofinity/PPOM Community Health Alliance(CHA South Bend) Compsychtel-Anthem (EJM/ EJN) Coresource Corvel Corporation (Workmans Comp) Coventry/First Health/ Personal Care of Illinois Cypress TPA Denies Insurance billing Direct Care America Emerald Health Employee Plans (TPA)- Sagamore Encircle Encore FedEX Insurance- Anthem GEHA Goshen Preferred Network Great West Healthcare GWH-Cigna Health Alliance Community health partners health plan Healthlink Health Payors Organization(HPO) Health Smart Hoosier Care Connect (HHC) Howard Regional Health System Humana ChoiceCare PPO Humana Medicare Advantage Indiana Health Network (HN) Indiana Lakes Managed Care PPO Indiana ProHealth Network Inspire Network Interplan Health Group IU Health IU Health Business Solutions Key Benefit Adminstrator Liberty Healthshare Lifesynch Lucent- Formerly North American Administrators Lutheran Preferred/Three Rivers Preferred Managed Health Services HIP/Hoosier Healthwise Managed Health Services/ Hoosier Care Connect MBHN Meritain MHS Medicaid Med Ben- Medical Mutual of Ohio Medi-Share Medicaid Medicaid MDWise Medicaid Anthem Medical Mutual of Ohio Medicare Railroad Medicare Traditional Medicare HMO Replacement Plans MDWise MDWise Marketplace Connect MDWise Eskanazi MDWise Excel HIP/Hoosier HealthWise(HHW) MDWise Methodist MDWise Select Health- Hoosier Healthwise/HIP MDWise St Catherine Hoosier Healthwise/HIP MDWise St Margaret Hoosier Healthwise/HIP MDWise St Vincent Hooseir Healthwise/HIP MDWise Total Health Hoosier Healthwise/HIP MHS MHS Medicaid Midwest Behavioral Health Multiplan PHCS Multiplan PHCS MySmarthealth NALC- National Assoc Letter Carriers National Association of Letter Carriers North American Administrators -Lucent Old German Baptist Brethren Optum Parkview Health Plan(Signature Care PPO) PBA- Professional benefit administrators PHCS(multiplan) PHP Preferred Plan Inc Proclaim Plus Prohealth Restricted Denies Insurance billing Sagamore Sagamore -Employee Plans - Cigna Samaritan Ministries Select Health Network(South Bend) Signature Care PPO(Parkview Health Plan) Siho(Inspire and Exchange Products) Smarthealth/Ascension/Anthem BCBS St Francis Health Network Three Rivers Preferred Tricare Standard UBH-United Behavioral Health UMR-United Medical Resources Unified Union contract insurance FedEX Insurance- Anthem United Behavioral Health United Healthcare United Medicare Advantage HMO/PPO
Adams Allen Bartholomew Benton Blackford Boone Brown Carroll Cass Clark Clay Clinton Crawford Daviess Dearborn Decatur De Kalb Delaware Dubois Elkhart Fayette Floyd Fountain Franklin Fulton Gibson Grant Greene Hamilton Hancock Harrison Hendricks Henry Howard Huntington Jackson Jasper Jay Jefferson Jennings Johnson Knox Kosciusko La Porte Lagrange Lake Lawrence Madison Marion Marshall Martin Miami Monroe Montgomery Morgan Newton Noble Ohio Orange Owen Parke Perry Pike Porter Posey Pulaski Putnam Randolph Ripley Rush St. Joseph Scott Shelby Spencer Starke Steuben Sullivan Switzerland Tippecanoe Tipton Union Vanderburgh Vermillion Vigo Wabash Warren Warrick Washington Wayne Wells White Whitley
White Black or African American American Indiana or Alaska Native Asian Native Hawaiian or Pacific Islander Multi-racial
Latino
Non-Latino
Does your patient currently have a treating mental health provider such as a therapist?
Yes
No
Do not know
If answered yes to above question, what kind of mental health provider does the patient have?
Is patient currently being treated for SUD, has been treated for SUD, or should be in treatment for SUD?
Yes
No
If answered yes to above question, what kind of SUD does the patient have?
Please select your reason(s) for contact
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Specific Reason for Contact
[What is provider's question or need for consultation?]
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(1-2 sentence summary of goals for consultation)
What are the diagnostic impressions or diagnoses of your patient? (Select all that apply)
Pre-contact medication (psychiatric meds) status
Never on psychiatric medications
Previously on psychiatric medications, but not within past 6 months
Recently (within past 6 months) but not currently on psychiatric medications
Currently taking psychiatric medications
Do not know
(psychiatric meds)
Primary CHAMP provider responding (Psychiatrist on
call)
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Dr. Michael Metrick Dr. Camila Arnaudo Dr. Sunil Patel Dr. Olawale Ojo Dr. David Diaz Dr. Diane Reis Dr. Aimee Patel Dr. Sara Culleton Dr. Michael Bushey Dr. Joanna Chambers Dr. Leah Stalnaker Dr. Dhrumil Patel Dr. Amy Ricke Dr. Susan Conroy Dr. Danielle Patterson Dr. Alexander Thomas Dr. Jonathan Withers Resource Question
(Psychiatrist on call)
Psychiatrist Email
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Time psychiatrist was paged
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Now H:M
Form completed by
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Dylan Bell Gloria Haynes Joe Clemmer