Form DCF-465R "Dcf Response" - Connecticut

What Is Form DCF-465R?

This is a legal form that was released by the Connecticut State Department of Children and Families - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2014;
  • The latest edition provided by the Connecticut State Department of Children and Families;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DCF-465R by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Children and Families.

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Download Form DCF-465R "Dcf Response" - Connecticut

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Connecticut Department of Children and Families
DCF RESPONSE
DCF-465R
8/14 (Rev.)
Page 1 of 1
THIS SECTION TO BE COMPLETED BY DCF
Child’s Name:
Date of Birth:
On Approved Medication List?
Yes
No
Reviewer findings and comments:
Labs and studies per protocol or other follow-up needed?
Yes
No.
Explain:
30 Day Approval - Per CMCU requirements baseline studies are required from providers requesting consent from DCF to start the following
medications: Lithium, Valproic Acid, Carbamazepine, Atypical Antipsychotics including Clozapine. Your response is approved pending the
submission of the result of a mandatory baseline study. Please resubmit the DCF-465 form with the mandatory baseline studies completed and
documented on the form within 30 days.
Reviewed by:
Paul Rao, 860-462-4494
Chris Malinowski, APRN, 860-704-4078
Angela Oide, APRN, 860-704-4143
Solnit Psychiatrist, 860-704-4035
Careline, 800-842-2288
Other :
Signature
Date:
Approved
Denied
Modified
Not Committed
Discontinuation
30 Day Approval
Denied-Baseline Incomplete
Notifications:
MHPD
Social Worker
RRG Nurse
CMCU
Prescribing Provider:
NOTE: Decisions may be appealed by the provider to the Chief of Psychiatry at: 860-704-4035
Connecticut Department of Children and Families
DCF RESPONSE
DCF-465R
8/14 (Rev.)
Page 1 of 1
THIS SECTION TO BE COMPLETED BY DCF
Child’s Name:
Date of Birth:
On Approved Medication List?
Yes
No
Reviewer findings and comments:
Labs and studies per protocol or other follow-up needed?
Yes
No.
Explain:
30 Day Approval - Per CMCU requirements baseline studies are required from providers requesting consent from DCF to start the following
medications: Lithium, Valproic Acid, Carbamazepine, Atypical Antipsychotics including Clozapine. Your response is approved pending the
submission of the result of a mandatory baseline study. Please resubmit the DCF-465 form with the mandatory baseline studies completed and
documented on the form within 30 days.
Reviewed by:
Paul Rao, 860-462-4494
Chris Malinowski, APRN, 860-704-4078
Angela Oide, APRN, 860-704-4143
Solnit Psychiatrist, 860-704-4035
Careline, 800-842-2288
Other :
Signature
Date:
Approved
Denied
Modified
Not Committed
Discontinuation
30 Day Approval
Denied-Baseline Incomplete
Notifications:
MHPD
Social Worker
RRG Nurse
CMCU
Prescribing Provider:
NOTE: Decisions may be appealed by the provider to the Chief of Psychiatry at: 860-704-4035