Get the free Landmark OTP Referral Form - CNY Services
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Landmark OTP Referral Form Central New York Services, Inc. Phone: 3156249835 DATE:1213 Court St. Suite 100 Utica, NY 13502 Fax: 3156249838 INDIVIDUAL INFORMATION DOB:NAME:ADDRESS:OK to send mail?
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How to fill out landmark otp referral form
How to fill out landmark otp referral form
01
Obtain the landmark OTP referral form from the designated authority or the Landmark OTP program.
02
Read the instructions carefully and gather all the required information and documents.
03
Fill out the patient's personal information such as name, date of birth, gender, and contact details.
04
Provide the relevant medical history and any previous treatment received for opioid addiction, if applicable.
05
Enter the referring healthcare provider's details including name, clinic or facility name, contact information, and signature.
06
Clearly state the reason for the referral and specify the requested services from the Landmark OTP program.
07
Attach any supporting documents, medical records, or test results that are necessary for the referral.
08
Review the completed form for accuracy and completeness.
09
Submit the filled-out form to the designated authority or the Landmark OTP program.
10
Wait for confirmation or further instructions from the program regarding the referral.
Who needs landmark otp referral form?
01
Individuals seeking treatment for opioid addiction or those who know someone in need of such treatment may need the Landmark OTP referral form.
02
Healthcare providers or clinicians who are referring patients to the Landmark OTP program also need to fill out this form.
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What is landmark otp referral form?
Landmark OTP referral form is a document used to refer patients to an opioid treatment program.
Who is required to file landmark otp referral form?
Healthcare providers and facilities are required to file the landmark OTP referral form.
How to fill out landmark otp referral form?
The landmark OTP referral form can be filled out by providing patient information, medical history, and reasons for referral to an opioid treatment program.
What is the purpose of landmark otp referral form?
The purpose of the landmark OTP referral form is to facilitate the referral process for patients in need of opioid treatment programs.
What information must be reported on landmark otp referral form?
Patient demographics, medical history, current medications, and reasons for referral must be reported on the landmark OTP referral form.
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