Get Health Partners Chemical Continued Service Request Form

Filling out the Health Partners Chemical Continued Service Request Form is an important step in ensuring individuals receive the necessary support for their chemical health needs. This guide will provide clear, step-by-step instructions to help users complete the form efficiently and accurately.

Follow the steps to successfully complete the form

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the facility name, telephone number, and the person completing this form along with their extension and fax number.
3. In the member information section, enter the member's name, member number, date of birth or age, and current diagnosis. Include the relevant axes (I, II, III, IV, V) as needed.
4. Proceed to Dimension 1, where you will indicate the risk level, last use date, and any current withdrawal concerns. Specify if the member has been given withdrawal medications.
5. Continue to Dimension 2 by assessing the risk level again and filling out current medical concerns and medications. Note any issues requiring 24-hour care.
6. In Dimension 3, identify the risk level and document any unresolved symptoms, as well as current mental health medications, their dosages, when they were started, and their purpose.
7. Evaluate if the member has considered suicide, if they engage in self-injurious behavior, and their ability to care for themselves.
8. In Dimensions 4 and 5, assess the member's readiness to change and any potential relapse triggers. Record treatment goals accomplished and those still pending.
9. In Dimension 6, provide details about the member's recovery environment, including their discharge location, support network, and participation in recovery meetings.
10. Finally, enter any additional information relating to the level of care requested, the number of days requested, admit date, and estimated discharge date. Attach any pertinent clinical information for review.
11. Once all sections are completed, review your entries for accuracy, then save changes, download, print, or share the form as necessary.

Complete your Health Partners Chemical Continued Service Request Form online today to ensure timely support.