Facility Medical Record #: Last 4 of SSN: ___Admitting State Hospital/ADATC: ___ DATE: ___ TIME: ___NC DIVISION OF MENTAL HEALTH/DEVELOPMENTAL DISABILITIES/SUBSTANCE ABUSE SERVICESRegional Referral.
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How to fill out the NC DMH 1-73-00 online
The NC DMH 1-73-00 form is a crucial document for the admission referral to a state psychiatric hospital or an Alcohol and Drug Abuse Treatment Center (ADATC). This guide provides comprehensive, step-by-step instructions for filling out the form online, ensuring clarity and ease for all users.
Follow the steps to complete the NC DMH 1-73-00 online.
- Use the ‘Get Form’ button to access the NC DMH 1-73-00 form and open it for editing.
- Fill in the section for 'Facility Medical Record #' and 'Last 4 of SSN' with the relevant information for the consumer or patient. Ensure accuracy as this information is vital for identification purposes.
- Complete the 'Admitting State Hospital/ADATC' field by entering the name of the facility. Include the date and time of the referral.
- Indicate the referral source by selecting from options such as 'Provider', 'LME/MCO', 'Self-Referral', 'ED/Hospital', or 'Other', and provide the name and contact number of the referral source.
- Enter the consumer or patient’s personal details including their full name, date of birth, gender, and any other names used. This ensures accurate identification.
- Describe the consumer’s current mental status and any applicable withdrawal symptoms or substance use information. Be detailed in your descriptions.
- Specify the type of admission, whether voluntary or involuntary, and provide any pertinent information regarding suicidal or homicidal thoughts.
- Document the principal diagnosis along with behavioral health and medical diagnoses, any psychosocial stressors, and the assessment of functioning measures.
- Include current medication details such as psychiatric and medical drugs, along with any noted side effects, allergies, and history of compliance with medications.
- When all fields are completed, users can save the changes, download, print, or share the form as needed to complete the referral process.
Complete the NC DMH 1-73-00 online to ensure a timely admission process.
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DMH 1-73-00 (Rev 10/2021). Page 1. Facility Medical Record #:. Admitting State...
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