Review referral - Hennepin County, Minnesota
Hennepin County ABH Case Management or ACT Team
New Client Authorization or Authorization Change
or Change in Client Status
FROM:
|* Case Manager Name: | |
|* Case Manager Fax Number: | |
|* Case Manager Email Address | |
|* Program Name: | |
|* Facility/Vendor Number: | |
Regarding:
|*Client Name: | |
|*Client Date of Birth: | |
|*Client Address, Apt. #, City, State, Zip | |
|*Client Social Security Number: | |
|Client PMI Number: | |
|Client SSIS Person Number: | |
|SSIS Work Group Number: | |
|Responsible County (if not Hennepin) | |
New Service or Renewal of Service:
|* Date of Authorization: | |
|* Length of Authorization: | |
|* Name of Service: (CM or ACT) | |
|* Service Code: | |
Change in Client Status:
|□ |Transferring Service To: (Name) | |
|□ |Went to IMD: (Name) | |
|□ |MA/PMAP Opened: (Name) | |
|□ |MA/PMAP Closed: (Name) | |
|□ |MA (disability type) opened: | |
|□ |MA (disability type) closed: | |
|□ |SNBC: | |
|□ |Other: | |
|□ |Question? | |
Fax To: Service Authorization Unit
Hennepin County Government Center
300 South 6th Street
Minneapolis, MN 55487
Fax Number: 612-632-8681
• (*) Notes a required field.
• Must include health care information.
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