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Legacy Health BHS Service Request Form 2018-2025 free printable template

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Legacy Medical Group Business Health ServicesService Request Form1475 Mt. Hood Avenue, Woodburn, OR 97071 legacyhealth.org/bhs Location map and directions on back of this form.BHS HAS MOVED. SAME
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How to fill out Legacy Health BHS Service Request Form

01
Obtain the Legacy Health BHS Service Request Form from the official website or clinic.
02
Fill out the patient's personal information including name, date of birth, and contact details.
03
Provide information regarding the patient's insurance details, if applicable.
04
Describe the specific mental health concerns or reasons for the service request in detail.
05
Indicate any previous treatments or evaluations the patient has received.
06
Complete the section regarding the urgency of the request (routine, urgent, etc.).
07
Sign and date the form to confirm the information is accurate and complete.
08
Submit the form to the appropriate Legacy Health BHS office via email, fax, or in person.

Who needs Legacy Health BHS Service Request Form?

01
Individuals seeking mental health services provided by Legacy Health BHS.
02
Family members or guardians looking to request services for a relative.
03
Healthcare providers referring patients for behavioral health services.
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The Legacy Health BHS Service Request Form is a document used to initiate a request for behavioral health services within the Legacy Health system.
The form is typically required to be filed by healthcare providers, case managers, or individuals requesting behavioral health services on behalf of a patient.
To fill out the form, provide accurate patient information, describe the specific behavioral health needs, and include any relevant medical history or previous treatment details.
The purpose of the form is to formally request services, facilitate the evaluation process, and ensure that individuals receive appropriate behavioral health support.
The form must report patient demographics, specific service requests, relevant medical history, and any previously received treatments or interventions.
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