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 filling out the petitioner information section. Enter the full name of the petitioner, including last, first, and middle names. Ensure accuracy as this information is crucial for identification.
3. Input the Illinois Driver’s License number, followed by the petitioner’s address including street, city, state, and ZIP code.
4. Indicate the petitioner's sex by selecting either 'M' for male or 'F' for female, and provide the date of birth in the specified format.
5. Provide the home and work telephone numbers in the appropriate fields, ensuring that the formatting is correct.
6. Complete the referral source field with the appropriate information regarding how the petitioner was referred for treatment.
7. Fill in the admission and discharge dates for the primary treatment, noting that this should not include follow-up or aftercare dates.
8. Document the admission and discharge diagnoses accurately, ensuring that this aligns with the treatment records.
9. Select the treatment modality utilized and report the corresponding hours or days completed in treatment.
10. Describe the prognosis following treatment, detailing the petitioner’s progress and reduction of future risks associated with alcohol or drug use.
11. Indicate the current status of continuing care, selecting from the available options and providing any necessary documents as required.
12. If applicable, provide a rationale for any modifications in treatment recommendations or waivers as described.
13. In the certification section, type the provider’s name, signature, date, title, telephone number, program name, and accreditation/license number.
14. Ensure all attached documents (Individualized Treatment Plan, Discharge Summary, Continuing Care Plan, Continuing Care Status Report, and Continuing Care Summary Report or TNA) are included before finalizing.
15. Once all fields are completed accurately, save changes, and download the document for printing or sharing as necessary.

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