Get Pm Form 3145 Request For Out-of-home Admission Adult

Filling out the PM Form 3145 is an important step for securing necessary out-of-home admission for adults. This guide will provide you with clear, step-by-step instructions on how to accurately complete the form online, ensuring a smooth submission process.

Follow the steps to complete your request efficiently.

1. Select the ‘Get Form’ button to access the form and open it in the editor.
2. Begin by entering the date of request in the designated field. Ensure that this date reflects when you are submitting the request.
3. Indicate the type of admission request by selecting either ‘Behavioral Health Residential Facility (BHRF)’ or ‘Behavioral Health Supportive Home (BHSH)’. If you are requesting a BHRF, specify whether it is for substance use disorder (SUD) or mental health treatment.
4. Fill in the member’s personal information, including their name, social security number (SSN), age, date of birth (DOB), and AHCCCS ID number. Ensure that all information is accurate.
5. Provide the member's mailing address and street address, ensuring to include city, state, and zip code.
6. Select the member's primary language from the options: English, Spanish, or other, specifying if you choose the latter.
7. Indicate the requestor's relationship to the member by selecting from the options provided.
8. Complete the behavioral health category and funding source sections by checking the relevant boxes.
9. Document the current living situation of the member by selecting the appropriate option from the provided list.
10. Provide details about the legal guardian if applicable, including their contact information.
11. Answer questions related to the recent behaviors, psychiatric symptoms, and psychosocial stressors, ensuring thorough documentation of the last three months.
12. Complete sections regarding the member's functional strengths and impairments, support systems, current diagnoses, and any medical issues.
13. Provide a comprehensive substance use history, detailing the class of substances, age of first use, amounts used, frequency of recent use, and date of last use.
14. Fill in the information regarding any previous behavioral health or substance abuse placements, including relevant details.
15. Check any outpatient services that have been provided in the last 90 days to meet the clinical needs driving the referral.
16. List current medications along with dosage and adherence levels.
17. Complete the mental status exam section, ensuring it was conducted within 30 days of submitting the request.
18. Provide necessary stakeholder information including legal history, current involvement with protective services, and discharge criteria.
19. Detail the goals and objectives for the proposed placement as well as any preliminary discharge plans.
20. Review all entered information for accuracy, then save changes and choose to download, print, or share the completed form as needed.

Ensure to submit your completed PM Form 3145 online for prompt processing of your request.