STATE OF Substance Abuse and Mental Health CLIENT SPECIFIC SERVICE EVENT FORM Client’s Name:___________________________________________________________ (Reference: Chapter 7, DCF Pam 155-2) ( * Mandatory Fields) Page 9-6 1 *Client SSN: __ - - __ Page 9-6 2. *Contractor ID: - If your agency is the subcontracted provider from Managing Entity, put the Managing Entity’s ID here. Page 9-6 3. *Service Date: __ __/ __ __/200__ Month Day Year Page 9-7 4. *Start Time: __ (HHMM) Page 9-7 – 5. *: __ __ 9-21 Page 9-21 6. *Program Type: ___ 1 - Mental Health 2 - Substance Abuse Page 9-21 7. *Provider ID: - __ __ __ __ __ __ Page 9-21 __ __ 8. *Setting: Page 9-23 9. *: __ __ Page 9-23 10. Procedure Code: __ __ __ __ __ (HIPAA Approved Procedures Codes only) Page 9-24 11. *Site Identifier: __ __ Page 9-24 12. Client ID: __ __ __ __ __ __ __ __ __ __ Page 9-24 13. *Provider Type: __ __ 01 - Counselors by subtype 09 - Physician/Osteopath by subtype 02 - Marriage & Family Therapist 10 Psychosocial – 03 - Therapist 11 - Rehabilitation 04 Neuropsychologist 12 - Specialist – 05 - Psychoanalyst by subtype 13 - School Psychologist 06 - Psychologist by subtype 14 - Social Worker 07 - Nursing service related 15 - Sociologist provider by type/subtype 16 - Other 08 - Physician assistant and advanced practice nursing providers by type/subtype
STATE OF Substance Abuse and Mental Health CLIENT SPECIFIC SERVICE EVENT FORM Client’s Name:___________________________________________________________ ( * Mandatory Fields) (Reference: Chapter 7, DCF Pam 155-2) 1 *Client SSN: __ - - __ Page 9-6 2. *Contractor ID: - If your agency is the subcontracted provider from Managing Entity, put the Managing Entity’s ID here. Page 9-6 3. *Service Date: __ __/ __ __/200__ Month Day Year Page 9-6 4. *Start Time: __ (HHMM) Page 9-7 5. *: __ __ Page 9-7 – 9-21 6. *Program Type: ___ 1 - Mental Health 2 - Substance Abuse Page 9-21 7. *Provider ID: - __ __ __ __ __ __ Page 9-21 8. *Setting: __ __ Page 9-21 9. *: __ __ Page 9-23 10. Procedure Code: __ __ __ __ __ (HIPAA Approved Procedures Codes only) Page 9-23 11. *Site Identifier: __ __ Page 9-24 12. Client ID: __ __ __ __ __ __ __ __ __ __ Page 9-24 13. *Provider Type: __ __ 01 - Counselors by subtype 09 - Physician/Osteopath by subtype 02 - Marriage & Family Therapist 10 – Psychosocial 03 - Therapist 11 - Rehabilitation 04 – Neuropsychologist 12 - Specialist 05 - Psychoanalyst by subtype 13 - School Psychologist 06 - Psychologist by subtype 14 - Social Worker 07 - Nursing service related 15 - Sociologist provider by type/subtype 16 - Other 08 - Physician assistant and advanced practice nursing providers by type/subtype Page 9-24
Form%20SERV.docx