Facility-Based Treatment Form

  1. Facility Information
  2. Patient Information
  3. Clinical Information

Please indicate whether you are requesting certification for initial or continued stay treatment. Fields marked with an asterisk are required. The certification is not valid until a certification number is issued.

Please indicate if this is:

Step One - Facility Information

Phone () -
Fax () -
UR Contact Number () -
UR Fax Number () -
Facility's Physical Address
Your Phone () -