Get Il Transdev Psychiatric Services Treatment Plan Form For Provider Type 36 2023-2025

This guide provides clear and supportive instructions for completing the IL Transdev Psychiatric Services Treatment Plan Form For Provider Type 36 online. Follow the steps outlined below to ensure that your form is filled out accurately and efficiently.

Follow the steps to complete the treatment plan form online.

1. Click ‘Get Form’ button to obtain the form and access it in the editor.
2. Begin by entering the participant's name in Section One. Provide their Recipient Identification Number, pickup address, city, state, and zip code. Be sure to include the start date and end date of the service along with the appointment time.
3. In Section Two, specify the transportation provider's name and phone number. Indicate the most appropriate or least expensive mode of transport and list any attendants that will accompany the participant.
4. Proceed to Section Three to answer whether there is a current Individual Treatment Plan (ITP) or Mental Health Assessment (MHA). Indicate the ITP or MHA date if applicable, and provide the DSM-IV-TR diagnosis for Axis I. Please note that transportation services do not cover vocational training or services not reimbursed by Medicaid.
5. Complete Section Four by entering the facility name, its phone number, and address. Fill in the LPHA (Licensed Practitioner of the Healing Arts) name, provider ID number, and LPHA phone number to validate the treatment plan. If applicable, provide the site number.
6. In the agreement and signature section, read the statement carefully. Upon agreeing, the LPHA must sign and date the form, certifying the accuracy of the information provided.
7. After filling out all sections, ensure all information is accurate and complete. Save your changes, and download, print, or share the completed form as required.

Complete your IL Transdev Psychiatric Services Treatment Plan Form online today to ensure efficient processing.