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DocuSign Envelope ID: 6FB1F3C4DEAC4688904A6C772179D4E8HCA Agreement Number: BENEFICIARY AGREEMENT Behavioral Health Workforce Stabilization FundingG255Beneficiary National PI Number: 1801003439This
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How to fill out beneficiary agreement behavioral health

01
Obtain a copy of the beneficiary agreement behavioral health form.
02
Read through the form carefully to understand the information required.
03
Fill in your personal details such as name, address, contact information, and date of birth.
04
Provide information about your behavioral health history and any current treatment you are receiving.
05
Review the form for accuracy and completeness before signing and dating it.

Who needs beneficiary agreement behavioral health?

01
Individuals who are receiving behavioral health services or treatment
02
Healthcare providers or facilities providing behavioral health services
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A beneficiary agreement in behavioral health is a formal document that outlines the rights and responsibilities of beneficiaries receiving mental health or substance use services, ensuring they understand the terms of their care.
Service providers offering behavioral health care services are typically required to file beneficiary agreements to comply with state and federal regulations.
To fill out a beneficiary agreement, the provider should include the beneficiary's details, the services to be provided, any rights they hold, and the responsibilities of both the provider and the beneficiary, ensuring all required fields are completed accurately.
The purpose of the beneficiary agreement is to clarify the expectations and responsibilities between the service provider and the beneficiary, ensuring informed consent and promoting better care delivery.
The agreement must report the beneficiary's name, the types of services to be provided, any risks involved, the beneficiary's rights, and contact information for support.
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