Follow the steps to successfully complete the registration template.

1. Click ‘Get Form’ button to obtain the registration template and access the document online.
2. Enter your Provider EDS/CMAP ID number at the top of the form, ensuring it is the 9-digit Medicaid ID.
3. Fill in the Facility/Provider Name and provide the Contact Number along with the extension.
4. Indicate the Facility/Provider Service Location. This should be the address where services will be provided.
5. Provide the name of the individual who is completing the form, including their credentials or title.
6. Enter the Member Name and the Medicaid/Consumer ID number, followed by the date of birth and/or social security number.
7. Select the appropriate Level of Care by checking the relevant box next to options like Intensive Outpatient or Case Management.
8. Answer the questions about the requested start date and whether this is a new registration, checking yes or no as applicable.
9. Identify the Referral Source by checking the applicable box. Options include Community Collaborative, Court-Ordered/Legal, and others.
10. Document the initial contact date and method (telephone or walk-in), ensuring all details are filled out accurately.
11. Continue filling in the required fields concerning behavioral and primary medical diagnoses, selecting all relevant checkboxes and providing necessary codes and descriptions.
12. Review all entered information for accuracy before saving the document. Once complete, you can download, print, or share the filled-out form as needed.

Start filling out your CT BHP Registration Template online today to ensure timely access to necessary services.