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Get CC PSR Service Authorization

DOB: Initial Assessment Date: Admission Date to Psychosocial Services: Assessor’s Name: Phone: Medicaid #: Retro Review? ☐Yes ☐No Request for approval of Psychosocial Services from (date)________________to (date) _______________ for a total of _____units of service. Diagnostic Information Axis I: Axis II: Axis III: Axis IV: Axis V: List of Known Medical Conditions List of Current Medications Prescribed Name of Medication Dosage Frequency Name of Prescriber Past Medication Complian.

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