AMERICAN SOCIETY OF ADDICTION MEDICINE (ASAM) FORM * Indicates Mandatory Data Elements: *Client SSN: ________________ *Contractor ID: ____________________ (Agency with ADM Contract) *Purpose: 1 Admission 2 - Continued Stay 3 Discharge – – *Evaluation Date: _____________________ *Provider ID: __________________ (Agency Providing the Services) *ASAM Date: ______________ *Substance Abuse Program: 2 Adult 4 Children – – Staff ID: __ __ - __ __ __ __ __ __ __ __ __ *Recommended ASAM Level of Care: 01 Residential Level 1 09 Outpatient Detoxification – – 02 Residential Level 2 11 Outpatient Treatment – – 03 Residential Level 3 12 Day/Night or Intensive Outpatient – – 04 Residential Level 4 14 Intervention – – 07 Substance Abuse Detoxification 17 Medication & Methadone Maintenance – – Treatment *Placement Begin Date: ___________ Placement End Date: ___________ *Actual Placement: ___________ (Use codes from Level of Care above) *Contract No 1: ___ ___ ___ ___ ___ Contract No 2: ___ ___ ___ ___ ___ Contract No 3: ___ ___ ___ ___ ___ Provider Information: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Signature: __________________________________________Date: _____/_____/________
AMERICAN SOCIETY OF ADDICTION MEDICINE (ASAM) FORM * Indicates Mandatory Data Elements: *Client SSN: ________________ *Contractor ID: ____________________ (Agency with ADM Contract) *Purpose: 1 – Admission 2 - Continued Stay 3 – Discharge *Evaluation Date: _____________________ *Provider ID: __________________ (Agency Providing the Services) *ASAM Date: ______________ *Substance Abuse Program: 2 – Adult 4 – Children Staff ID: __ __ - __ __ __ __ __ __ __ __ __ *Recommended ASAM Level of Care: 01 – Residential Level 1 09 – Outpatient Detoxification 02 – Residential Level 2 11 – Outpatient Treatment 03 – Residential Level 3 12 – Day/Night or Intensive Outpatient 04 – Residential Level 4 14 – Intervention 07 – Substance Abuse Detoxification 17 – Medication & Methadone Maintenance Treatment *Placement Begin Date: ___________ Placement End Date: ___________ *Actual Placement: ___________ (Use codes from Level of Care above) *Contract No 1: ___ ___ ___ ___ ___ Contract No 2: ___ ___ ___ ___ ___ Contract No 3: ___ ___ ___ ___ ___ Provider Information: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Signature: __________________________________________Date: _____/_____/________