Follow the steps to complete the Tufts Esp Notification Form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter today's date in the designated field. Make sure you format it as MM/DD/YYYY for consistency.
3. Complete the ESP evaluation section by entering the time of member readiness, the time evaluation was started, and the time evaluation was completed.
4. Fill out the member information fields, including the member's name, ID number, address, city, state, ZIP code, phone number, and date of birth.
5. In the ESP information section, provide the name of the ESP clinician or contact, the ESP name, site location, and contact phone number.
6. Select the type of notification by indicating whether it is pending admission, looking for placement, or if an admission has been arranged.
7. Indicate the member's current location by checking the appropriate box, such as at home, in a hospital emergency room, or other specified location including the name of the hospital if applicable.
8. List the level of care for which admission is being arranged. Options may include inpatient mental health services or various substance use disorder services.
9. If admission has been arranged, provide the name and address of the hospital or facility, including city, state, and ZIP code.
10. Specify the diagnosis by including the relevant ICD 10 code.
11. Print your name as the ESP clinician completing this form, and enter the date at the bottom of the form.
12. Once all information is accurately filled, you may save changes, download, print, or share the form as required.

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