Get the free 031717 ADHS BH Referral Form pm - Phoenix Health Plan

PM Form 3.3.1 ADDS/DBMS REFERRAL FOR BEHAVIORAL HEALTH SERVICES Print Form I. Information on Person Making Referral Name and Title Today's Date and Time: Phone Affiliated Agency Type of Service Requested:

How to fill out 031717 adhs bh referral

How to fill out 031717 adhs bh referral:

1. Start by entering the patient's personal information such as their name, date of birth, address, and contact information in the appropriate fields.
2. Next, indicate the referring healthcare provider's information, including their name, contact information, and the facility or organization they are affiliated with.
3. Provide details on the patient's medical history, including any previous diagnoses, treatments, and medications they have received for ADHD or other related conditions.
4. Describe the reason for the referral and the specific services or evaluations requested from the Behavioral Health specialist.
5. Include any relevant supporting documentation or test results that may assist the Behavioral Health specialist in providing appropriate care.
6. Finally, review the completed referral form for accuracy and completeness before submitting it to the designated recipient.

Who needs 031717 adhs bh referral:

1. Patients who have been diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) and require specialized Behavioral Health services may need to obtain a 031717 adhs bh referral.
2. This referral may also be necessary for individuals who have been displaying symptoms of ADHD and need a comprehensive evaluation or treatment plan from a qualified Behavioral Health specialist.
3. Healthcare providers, such as primary care physicians or pediatricians, who are unable to manage or treat ADHD on their own may also refer their patients to a Behavioral Health specialist using this referral form.

For pdfFiller’s FAQs

What is 031717 adhs bh referral?

031717 adhs bh referral is a form used for referring individuals to behavioral health services.

Who is required to file 031717 adhs bh referral?

Healthcare providers, social workers, counselors, and other professionals working with individuals in need of behavioral health services are required to file 031717 adhs bh referral.

How to fill out 031717 adhs bh referral?

To fill out 031717 adhs bh referral, the required information about the individual's condition, needs, and contact information must be provided on the form, along with the provider's information and signatures.

What is the purpose of 031717 adhs bh referral?

The purpose of 031717 adhs bh referral is to ensure individuals in need of behavioral health services are connected to the appropriate resources and support.

What information must be reported on 031717 adhs bh referral?

Information such as the individual's demographics, medical history, behavioral health needs, and contact information must be reported on 031717 adhs bh referral.

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