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Get PA Magellan Behavioral Health Initial Referral For Family-Based Services 2014-2024

Uation must be attached. Complete all four pages and fax to 866-667-7744. Date of Referral: Referring Agency Provider #: Referring Agency Staff: Referring Agency Phone: Referring Agency: Referring Agency Fax #: Recommended FBS Provider: Rationale, if applicable (clinical reason, family, reference, etc.): Parent/guardian/member over age 14 gave consent for release of information: Written Consent: Yes No Date Received: CONSENT MUST BE GIVEN BEFORE A PROVIDER CAN RECEIVE THE CLINICAL INFO.

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