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San Francisco Department of Public Health Community Programs Placement Behavioral Health Access Center (BHAC)

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Community Behavioral Health Services 2712 Mission Street 1380 Howard St. 1 Fl Ste., 100
San Francisco, CA 94110 San Francisco, CA 94103
(415) 401-2638 General Questions (415) 503-4730 – Main Number
(415) 401-2629 Placement Fax (415) 255-3629 BHAC FAX

Placement Authorization Request Form

Client Name (AKA if known) SSN DOB BIS Number (if available)

Program client is currently at Provider RU# (if known)

Is Client a SF resident? € Yes € No Where was client last 30 days?

Entitlements: € Medi-cal € Medicare € SSI Other Income Source:

Conservator Status: € T-Con € Permanent LPS € Probate Conservator Name:

SPR CLIENT: € Yes € No € Pending PLEASE NOTE, IF SPR CLIENT, APPROVAL IS REQUIRED

SPR Clinician Tel:

HAS ICM: € Yes € No € Pending ICM Clinician Tel:

Level of Care Requested: DSM IV-TR Diagnoses:

Clinical Indications for Level of Care Request

Recommended Treatment Goals:

Submitted By: Date:

Telephone #: Fax #:

PLACEMENT RECOMMEDATIONS € PLACEMENT AUTHORIZED

€ Dual Dx Res € Transitional Res € LSAT € Clay/Loso € Our House € RCF/E € Med Supported Detox

€ AOD Social Model Detox € AOD Social Model Res €Co-Op € Support Service Hotel € Hotel
Specify

€ NOT AUTHORIZED REASON:

Authorizing Clinician Date


Authorizer Form Rev: 08/17/10