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DISCHARGE CONSULTATION DOCUMENTATION Please complete all information requested on this form. SUBMIT TO Utilization Management Department 12515-8 Research Blvd. Suite 400 Austin Texas 78759 FAX 1. 866. 535. 6974 Member Name DOB Member ID Parent/Guardian Address Phone Best time to reach member/parent/guardian Emergency and/or Additional Point of Contact Phone Outpatient Therapist Phone Date of next appointment Case Manager if applicable Phone Psychiatrist Phone Date of next appointment Does the...
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How to fill out member name dob
How to fill out member name dob
01
Step 1: Start by locating the member name dob section on the form.
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Step 2: Enter the member's full name accurately in the designated space.
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Step 3: Enter the member's date of birth accurately in the specified format (e.g., dd/mm/yyyy or mm/dd/yyyy).
04
Step 4: Double-check the filled information for any errors or missing details.
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Step 5: If everything is correct, submit the form as required.
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What is member name dob?
Member name dob refers to the Date of Birth of the individual
Who is required to file member name dob?
Any entity or individual who collects personal information for record keeping purposes is required to file member name dob
How to fill out member name dob?
Member name dob can be filled out by entering the individual's date of birth in the designated field
What is the purpose of member name dob?
The purpose of member name dob is to accurately record the date of birth of an individual for identification and record keeping purposes
What information must be reported on member name dob?
The information reported on member name dob is the date of birth of the individual
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