"Csat/Opat Detox Exception Request and Record of Justification" - Connecticut

Csat/Opat Detox Exception Request and Record of Justification is a legal document that was released by the Connecticut Department of Mental Health & Addiction Services - a government authority operating within Connecticut.

Form Details:

  • Released on August 31, 2001;
  • The latest edition currently provided by the Connecticut Department of Mental Health & Addiction Services;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Connecticut Department of Mental Health & Addiction Services.

ADVERTISEMENT
ADVERTISEMENT

Download "Csat/Opat Detox Exception Request and Record of Justification" - Connecticut

1043 times
Rate (4.6 / 5) 73 votes
State of Connecticut
Department of Mental Health and Addiction Services
CSAT/OPAT DETOX EXCEPTION REQUEST and RECORD of JUSTIFICATION
DATE:
PROGRAM NAME:
PROGRAM ID #
PROGRAM TELEPHONE #:
PROGRAM FAX #:
PROGRAM E-MAIL ADDRESS:
PATIENT ID #
PATIENT AGE:
CITY/TOWN OF RESIDENCE
!
!
!
!
SOURCE OF PAYMENT:
Indigent
SAGA
Title 19
SSI
!
!
Commercial Insurance
Other
Number of detoxes in this program in past 12 months:
Date of last detox in this program, PTA:
Did the physician justify this current detox episode and assess the patient for other forms of treatment as required
by 42 CFR, Part 8-12 (e) (4)?
!
!
YES
NO
J
F
T
A
:
USTIFICATION
OR
HIS
DMISSION
!
!
Pregnant Female
Medical condition (e.g. hypotension) has potential to complicate withdrawal
!
!
Patient unwilling to consider methadone maintenance
On waiting list for maintenance
!
!
Requires detoxification from both alcohol and heroin
Co-occurring psychiatric disorder
!
Other:
Physician’s Name
Physician’s Signature
Federal HHS: CSAT/OPAT
Fax: (301) 443-3994
!
!
Approved
Denied
Signature
Date
Explanation:
Note:
Programs are to send a copy of each exception request to the State Methadone Authority, fax number (860) 418-6691. Prior authorization by the
SMA is not required, at this time, for exceptions to the two detox per year limit in Connecticut.
State of Connecticut
Department of Mental Health and Addiction Services
CSAT/OPAT DETOX EXCEPTION REQUEST and RECORD of JUSTIFICATION
DATE:
PROGRAM NAME:
PROGRAM ID #
PROGRAM TELEPHONE #:
PROGRAM FAX #:
PROGRAM E-MAIL ADDRESS:
PATIENT ID #
PATIENT AGE:
CITY/TOWN OF RESIDENCE
!
!
!
!
SOURCE OF PAYMENT:
Indigent
SAGA
Title 19
SSI
!
!
Commercial Insurance
Other
Number of detoxes in this program in past 12 months:
Date of last detox in this program, PTA:
Did the physician justify this current detox episode and assess the patient for other forms of treatment as required
by 42 CFR, Part 8-12 (e) (4)?
!
!
YES
NO
J
F
T
A
:
USTIFICATION
OR
HIS
DMISSION
!
!
Pregnant Female
Medical condition (e.g. hypotension) has potential to complicate withdrawal
!
!
Patient unwilling to consider methadone maintenance
On waiting list for maintenance
!
!
Requires detoxification from both alcohol and heroin
Co-occurring psychiatric disorder
!
Other:
Physician’s Name
Physician’s Signature
Federal HHS: CSAT/OPAT
Fax: (301) 443-3994
!
!
Approved
Denied
Signature
Date
Explanation:
Note:
Programs are to send a copy of each exception request to the State Methadone Authority, fax number (860) 418-6691. Prior authorization by the
SMA is not required, at this time, for exceptions to the two detox per year limit in Connecticut.
State of Connecticut
Department of Mental Health and Addiction Services
CSAT/OPAT DETOX EXCEPTION REQUEST and RECORD of JUSTIFICATION
A:\CSAT – Detox Execption From rev. 8-31-01/smd
Page of 2