Continued Outpatient Mental Health Treatment Request Form

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

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

Please note: If you have been requesting these or similar services for this patient for three years or more, please use the Extended Outpatient Mental Health Treatment Request form.

Step One - Clinician Information

Outpatient clinics please use same NPI for both fields.

Phone () -
Fax () -