Follow the steps to successfully complete the Dsohf 5 87a 12 Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill out the facility medical record number and the last four digits of the social security number as requested.
3. Specify the admitting state hospital or ADATC, along with the date and time of the referral.
4. Indicate the referral source by selecting from the options: Provider, LME, Self-Referral, or Other, and fill in the name and contact details of the referral source.
5. Enter the consumer/patient’s full name, date of birth, and any other names used by the consumer.
6. Check the appropriate gender option and provide the legal guardian's or parent's name, along with their relationship to the consumer.
7. Complete the contact details of the consumer, including address and phone number.
8. Indicate the consumer’s ethnicity and county of residence.
9. Select the type of admission: voluntary or involuntary, and indicate if the consumer is currently suicidal or homicidal.
10. Provide mental status information and describe any withdrawal symptoms.
11. If applicable, fill out the substance use information detailing the drugs used, routes, and frequency.
12. Select the appropriate ASAM PPC-2R Criteria level for the referral.
13. Complete sections related to the consumer's medical and psychiatric history, including previous admissions and current medications.
14. Describe the hospitalization goals, treatment objectives, proposed discharge plans, and any additional resources.
15. Complete the third-party coverage information, if applicable.
16. Review all sections for accuracy and completeness before saving your changes.
17. Once all information is filled out, save the form and download or print it for submission.

Complete the Dsohf 5 87a 12 Form online today for efficient and accurate processing.