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SUBMIT TO: Utilization Management Department 125158 Research Blvd., Suite 400 Austin, Texas 78759 PHONE 1.877.687.1169 FAX 1.855.279.6165 OUTPATIENT TREATMENT REQUEST FORM Please print clearly incomplete
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What is has contact occurred with?
Contact occurred with another person or entity.
Who is required to file has contact occurred with?
Anyone who has had contact with another person or entity.
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You can fill out the contact occurred with by providing relevant details such as date, time, location, and nature of contact.
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The purpose of reporting contact occurred with is to track interactions for reference and analysis purposes.
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Information such as date, time, location, and nature of contact must be reported on contact occurred with.
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