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Provider Forms

Other Clinical Forms

ECT

ECT Outpatient Concurrent Request

ECT Outpatient Initial Request

Mental Health

Higher Level of Care Concurrent Request

Higher Level of Care Initial Request

PHP-IOP Concurrent Request

PHP-IOP Initial Request

Residential Bed Hold Request

Mobile Treatment

Mobile Treatment - Adult Concurrent

Mobile Treatment - Adult Initial

Mobile Treatment Child and Adolescent Concurrent Request

Mobile Treatment Child and Adolescent Initial Request

Psychological Testing

Psychological Testing Request - Adult

Psychological Testing Request - Child

Specialized Rehabilitation Program

Specialized Rehabilitation Program – Concurrent Request

Specialized Rehabilitation Program – Initial Request

Substance Use Disorder

Withdrawal Management Substance Use Disorder-Higher Level of Care Concurrent Form

Withdrawal Management Substance Use Disorder-Higher Level of Care Initial Form

Substance Use Disorder Ambulatory Detox – PHP-IOP Concurrent Request

Substance Use Disorder Ambulatory Detox – PHP Initial Request

Substance Use Disorder - Higher Level of Care Concurrent Request

Substance Use Disorder - Higher Level of Care Initial Request

Substance Use Disorder - IOP Request

Target Case Management

Target Case Management

Target Case Management – Child and Adolescent – Level I & II

Target Case Management Level III Request

TBS

TBS Assessment Request

TBS Treatment Request

TBS Subsequent - Concurrent

Transcranial Magnetic Stimulation

Transcranial Magnetic Stimulation - Concurrent Request

Transcranial Magnetic Stimulation - Initial Request

Clinical Discharge

Clinical Discharge

Inpatient Administrative Day Request

Inpatient Administrative Day Request

Respite Service Request

Respite Service Request