Get Pcpc Summary Sheet

This guide provides a comprehensive overview of how to effectively fill out the Pcpc Summary Sheet for drug and alcohol treatment providers. By following these steps, users can ensure accurate completion and submission of this important document.

Follow the steps to complete the Pcpc Summary Sheet successfully.

1. Click ‘Get Form’ button to access the Pcpc Summary Sheet and open it in the online editor.
2. Begin by filling in the 'Member Name' field with the individual's full name. Ensure that all information is accurate and up-to-date.
3. In the 'Reviewer/Therapist' section, input the name of the reviewer or therapist overseeing the case.
4. Specify the 'Facility' where the treatment is being provided. Choose from the drop-down options available.
5. Indicate the '# of Sessions Requested' by selecting the appropriate quantity from the provided options.
6. In the 'Treatment Type' section, select the type of treatment that the individual requires.
7. Complete the 'Expected Frequency' field, detailing how often the individual will need the specified treatment.
8. For 'Service Request,' indicate the specific services being requested by selecting the most relevant options.
9. Fill in the admission details such as 'From' and 'To' dates, as well as the 'Projected Termination Date' for the session.
10. Provide the 'MA ID #' (if applicable) and a contact number in the 'Phone #' field.
11. In the 'Discharge Plan in Place' area, indicate whether a discharge plan has been established by selecting 'Yes' or 'No.'
12. Indicate the recommended level of care and specify the program or facility being referred to in the designated section.
13. Complete the criteria sections by indicating the level of care and criteria for each relevant dimension. Consider factors such as intoxication, biomedical conditions, emotional/behavioral status, and recovery environment.
14. Add brief comments regarding the member’s progress or status in each dimension. If applicable, detail the amount, duration, and last use for each substance in Dimension 1.
15. Once all sections are completed, you can save your changes, download a copy, print the document, or share it as needed.

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