Psychiatric and substance abuse outpatient authorization form fax to (701) 2772253 mail to bcbsnd attn: health network innovation 4510 13th ave s fargo, nd 58121 please complete and fax the entire form and attach appropriate clinical documents....
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Pattison professional counseling center 259 east oakdale avenue, crestview, fl 32539 7 vine avenue, ne, fort walton beach, fl 32548 name date: first middle last address street city state zip home phone work phone cell phone social security number...
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1. date of request (ymmdd) route order amendment part i - request for amendment 3. from: (name, address and zip code of requesting agency) 2. to: (sddc routing authority) 4. route order number 5. identification number (requesting agency) 6. type...
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Registration form registrant information check all that apply: ? board member ? public member ? board administrator ? first-time attendee ? associate member ? other ? pt ? pta fees includes three days of programming, early bird by 2/1 advance by...
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Substance abuse individualized recovery treatment plan consumer name: date of admission: diagnosis estimated length of stay level of care i hours/week continued stay (circle one): 60 days 10 hours staff responsible: problem statement (in clients...
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