Outpatient Medication Management Form

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Instructions

Only providers with prescriptive authority can use this form. Fields marked with an asterisk are required. The certification is not valid until a certification number is issued.

Clinician Information

Clinician's First Name

Clinician's Last Name

Please Specify "Other"

Clinician's NPI

Group's NPI

Outpatient clinics please use same NPI for both fields.

Phone Area Code () First Three Digits - Last Four Digits

Fax Area Code () First Three Digits - Last Four Digits

Clinician Email

Mailing Address 1

Address 2

ZIP Code

City

Contact's First Name

Contact's Last Name

Contact's Extension

Patient Information

Patient's First Name

Patient's Last Name

Date of Birth

ID Card Number

Phone Area Code () First Three Digits - Last Four Digits

Patient Email

Clinical Information

Diagnosis or Presenting Symptoms:

Diagnosis

Presenting Symptoms

Diagnosis

Presenting Symptoms Max characters: 200

GAF Score

If you want to request other services, use one of our outpatient mental health treatment forms.

Certification Start Date

mm/dd/yyyy

Companion Benefit Alternatives, Inc.

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