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Get BCN Behavioral Health IP/PHP/IOP Concurrernt Review Form

Name: Primary care practitioner / Last name: First name: Offered / signed Date: Offered / declined PCP release of information: Date: Date(s) PCP communication occurred: B Member s legal status Legal status: Voluntary Does member have: Involuntary Guardian If involuntary: Deferred Durable power of attorney Court / date: N/A Contact information for guardian / DPOA (if applicable): C Justification for continued stay Acute suicidal ideation with plan / intent (in.

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