Get Ma Mclean Southeast Adult Partial Hospital Program Referral Form 2022-2025

Filling out the MA McLean SouthEast Adult Partial Hospital Program Referral Form accurately is essential for processing referrals efficiently. This guide will provide you with step-by-step instructions to complete the form online, ensuring all required information is provided.

Follow the steps to fill out the form online:

1. Click ‘Get Form’ button to obtain the form and open it in your online document editor.
2. Enter the date of referral in the designated field. This is the date you submit the form.
3. Complete the patient information section, including the patient's name, date of birth, address, home phone, cell phone, and email. Ensure that all details are accurate and up to date.
4. Provide the patient's occupation, living situation, and transportation details to the Partial Hospital Program in the respective fields.
5. Fill out the referral information, including who referred the patient and their contact phone number.
6. In the insurance section, fill in the insurance company name, phone number for benefits verification, insurance ID number, group number, and subscriber details, including their date of birth.
7. Describe why the patient currently requires a partial hospital level of care in the provided space.
8. Outline the goals for referral to the MSE Partial Hospital Program.
9. List any psychiatric diagnoses the patient has received.
10. Provide information on any previous inpatient or detox hospitalizations, specifying dates, facilities, and reasons.
11. Complete the substance use history section, detailing any relevant drug usage, and indicate frequency, amount, and duration of use.
12. Include information regarding any history of eating disorders, suicide attempts, self-injurious behavior, trauma, and current safety status.
13. List current medications and dosages, along with any last blood level results if applicable.
14. Document any medical conditions and allergies the patient has.
15. Provide details about the current outpatient treatment team, including therapists, pharmacologists, and primary care providers.
16. Indicate if there are any court dates or legal problems, and provide explanations if necessary.
17. Sign and print your name in the designated areas at the end of the form.
18. Lastly, ensure all required documents, such as the admission note, history/physical, and psych testing (if available), are attached before submitting.
19. Save changes, download, print, or share the completed form as necessary.

Complete the MA McLean SouthEast Adult Partial Hospital Program Referral Form online today to ensure timely processing of the referral.