Outpatient Substance Use Disorder Treatment Request Form

  1. Clinician Information
  2. Patient Information
  3. Clinical Information

Fields marked with an asterisk are required. The certification is not valid until a certification number is issued.

Step One - Clinician Information

Please provide either the clinician information or the facility information.

Clinician Information

Phone () -
Fax () -
Facility Information
Facility's Phone () -