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Mercy Care Notification of Subacute Detox AdmissionAdmission Fax # 8558253165
This form must be completed entirely and faxed to above number to obtain an authorization
for this admissionProvider Name
Facility
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How to fill out sub-acute detox admission form
How to fill out sub-acute detox admission form
01
Obtain the sub-acute detox admission form from the facility or online.
02
Fill in the patient's personal information such as name, date of birth, address, and contact information.
03
Provide details about the patient's medical history, including any past diagnoses, medications, and treatments.
04
Indicate the reason for admission to the sub-acute detox program and any relevant substance abuse history.
05
Sign and date the form, confirming that all the information provided is accurate and complete.
Who needs sub-acute detox admission form?
01
Individuals who are seeking treatment for substance abuse and require a supervised detoxification process may need to fill out a sub-acute detox admission form.
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What is sub-acute detox admission form?
The sub-acute detox admission form is a document used to admit individuals to a sub-acute detox facility for the purposes of detoxification and treatment of substance abuse.
Who is required to file sub-acute detox admission form?
Healthcare professionals such as doctors, nurses, and social workers are required to file the sub-acute detox admission form on behalf of patients who need detoxification services.
How to fill out sub-acute detox admission form?
The form must be completed by providing the patient's personal information, medical history, substance abuse details, and consent for treatment.
What is the purpose of sub-acute detox admission form?
The purpose of the sub-acute detox admission form is to ensure that patients receive appropriate care and treatment for substance abuse issues in a supervised medical setting.
What information must be reported on sub-acute detox admission form?
The form must include the patient's name, date of birth, contact information, medical history, substance abuse history, insurance details, and consent for treatment.
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