SC Department of Mental Health Initial Outpatient Treatment Request Form

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Instructions

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

Clinic Information

Clinic's Name

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

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

Clinic Email

Clinic's NPI

Contact's First Name

Contact's Last Name

Contact's Extension

Clinic's Mailing Address

Mailing Address 1

Address 2

ZIP Code

City

Patient Information

Patient's First Name

Patient's Last Name

Date of Birth

mm/dd/yyyy

ID Card Number

Patient CIN

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

Patient Email

Clinical Information

What Service(s) Are You Requesting? (Choose all that apply.)

MMO-Medically Monitored Only

Management & Treatment Services

Injectable Track Services

Diagnosis or Presenting Symptoms: Max characters: 1000

When is the Patient's First Appointment?

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.

Companion Benefit Alternatives, Inc.

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