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 CBA issues a certification number.

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 () -