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Mental/Behavioral Health SUPPLEMENTAL APPLICATION THIS APP LI C A TI ON M US T A C OM PA N Y The Hums AN S ERV C ES AD VA NT AGE S U PP LEM EN TA L APP LIC ATI ON Applicant Name: AGENCY PROGRAMS:
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It is a supplement form related to mental and behavioral health services provided by Hanover.
Healthcare providers and facilities offering mental and behavioral health services are required to file this form.
The form must be filled out accurately and completely with all relevant information regarding mental and behavioral health services provided.
The purpose of the form is to report and document information related to mental and behavioral health services provided by Hanover.
Information such as types of services provided, number of patients treated, medications prescribed, and outcomes of treatment must be reported.
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