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This Request is to be completed (typed) by the current treating clinician or case manager if RSHA funding for a behavioral health placement has been requested. Send by secure fax to 18666010111 Incomplete
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This request is to formally request for specific information or action.
The individual or entity specified in the request is required to file it.
The request can be filled out by providing the necessary information in the designated fields.
The purpose of this request is to obtain the required information or action.
The specific information that needs to be reported will be outlined in the request form.
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