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 CBA issues a certification number.

Step One - Clinician Information

Please provide either the clinician information or the facility information.

Clinician Information

Outpatient clinics please use same NPI for both fields.

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