Patient Information
Patient Name
Date of Birth
Member ID
Phone
Address
Provider Information
Provider Name
Provider NPI
Phone
Fax
Email
Treatment Information
Type of Request
Initial
Concurrent
Treatment Start Date
Requested Level of Care
Detoxification
Inpatient
Residential
Partial Hospitalization
Intensive Outpatient
Outpatient
Other
ICD-10 Diagnosis Codes
Substance(s) Used
Treatment History
Current Symptoms/Risk Factors
Medications
Additional Clinical Information