Authorization of Secure Ambulance Transportation to or ... - Washington
Authorization of Secure Ambulance Transportation to/from Behavioral Health Services
Purpose
The Authorization of Secure Ambulance Transportation to/from Inpatient Behavioral Health Services form supplies demographic information necessary for the creation of eligibility for an individual without active Medicaid coverage.
Client Name (Last, First, Middle Initial)
Date of transport
ProviderOne Client ID (If Applicable)
AddressCityStateZIP Code
County of Residence Birthdate (MM/DD/YYYY)SSN Service Status (check the appropriate box)
Homeless
Transient
Other:
Gender
Male Female
Voluntary Involuntary
Voluntary Services Attestation
By signing below, I certify that the above-named individual has been assessed by an Emergency Room Doctor/ Attending Physician and found to meet criteria for voluntary behavioral health services and is not detained or committed pursuant to RCW 71.05 or 71.34.
Signature of Medical Professional
Date
Involuntary services
The section below is for involuntary services and must be completed by a Designated Crisis Responder (DCR).
Reason for detention (check all that apply):
ITA status at time of transport:
Danger to self
Detained
Danger to others
Committed
Gravely disabled
LRA/CR revoked
LRA revocation
LRA = Less restrictive alternative
Danger to property
CR = Conditional release
Date of detention Destination facility name
Destination county
DCR Attestations
By signing below, I certify that the following statements are true: ? The above-named individual has been assessed by a DCR and found to meet criteria for detention/ revoca-
tion/commitment, per RCW 71.05, or RCW 71.34. ? I am authorized to take said individual or cause said individual to be taken into custody and placed into a
treatment facility or crisis center, per RCW 71.05.150(4), or RCW 71.05.153(1). ? The individual named above has been detained, committed, or is being returned to the hospital by a petition
for detention/revocation or an order of commitment pursuant to RCW 71.05, or RCW 71.34.
Name of DCR (print)
Signature of DCR
Date
Behavioral Health Administrative Service Organization (BH-ASO) or Behavioral Health Organization (BHO) -- including county: PROVIDER: Attach a completed copy of this form, to your claim submission; keep the original in the client's file.
HCA 42-0003 (12/19)
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- behavioral health emergency services under e2shb 1688 mike kreidler
- behavior rehabilitation services handbook washington department of
- transforming washington s behavioral health care system
- washington state behavioral health communication framework
- behavioral health services only enrollment washington
- washington state department of social and health services division of
- washington summary state residential treatment for behavioral health
- major federal and washington state laws related to access to behavioral
- 2020 behavioral health provider services reference guide washington
- washington state s behavioral health benefits book
Related searches
- important to or for me
- do to or due to
- promoted to or promoted as
- do to or due to grammar
- due to or do to grammar
- authorization of medication consent form
- written authorization of consent form
- teaching transportation to preschoolers
- denver airport transportation to breckenridge
- free transportation to medical appointments
- city of henderson ambulance billing
- authorization of payoff form