SC Department of Mental Health Initial Outpatient Treatment Request Form

Instructions

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

Clinic Information
Phone () -
Fax () -
Clinic's Mailing Address
Patient Information

mm/dd/yyyy

Phone () -
Clinical Information
What Service(s) Are You Requesting? (Choose all that apply.)
Max characters: 1000

mm/dd/yyyy


Certifications only apply to services authorized for reimbursement in the Clinic Agreement between CBA and SC DMH. Approval of continued services requires the clinic to get further certification from CBA.