Documents
Instructions
Updated 5/2017
Use
Counselor requests that the treating physician, clinic, or hospital complete the form. The information is used to help determine eligibility for services.
Copies and Distribution
No copies are required. The original is filed in the consumer’s paper file. If guidance on the case is requested from the state medical director, a copy of the form is included in the courtesy file.
Retention
The completed form is part of the consumer’s paper file and is retained until the end of the fiscal year the case is closed, plus five years.
Special Instructions
This form is referenced in RPM Chapter 3: Eligibility 3.8.2 Policy.