Facility-Based Treatment | Healthy Blue - Healthy Connections Form Resource Center

Facility-Based Treatment

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Facility-Based Treatment Form

Use this form to request certification for both mental health and substance use disorder treatment for inpatient, residential treatment (RTC), partial hospitalization (PHP), intensive outpatient (IOP) or outpatient electroconvulsive therapy services.
Discharge Form

Use this form when a patient is being discharged from an inpatient or residential treatment center (RTC).