Faxing Details

Form Trs 48 is a necessary document for businesses in Texas. This form is used to report certain information about the business, including its name and address, as well as the names and addresses of its officers. Filing this form is required by the Texas Secretary of State's office. For more information on what to include on Form Trs 48, read on below.

Listed below are some specifics of form trs 48. You may want to read it before writing the gaps.

QuestionAnswer
Form NameForm Trs 48
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names

Form Preview Example

PATIENT NUMBER:

SCHEDULED ADMISSION DATE:

STUTZMAN ADDICTION TREATMENT CENTER

CLIENT REFERRAL FORM

Fax this form, psychosocial assessment, medical information, and any recent lab work to:

ADMISSIONS OFFICE FAX NUMBER (716) 882- 4542.

After faxing the requested information, please call (716) 882-4906 for an admission date.

Client Information

Sex:

 

 

 

Male

 

 

 

Female

 

 

Transgender

 

 

 

Veteran:

 

 

Yes

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Client Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

County:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No Permanent Address

 

 

 

 

No Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Full Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Town/City/State:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Zip Code:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone Number:

 

 

 

 

 

 

OR

 

Contact Number :

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Age:

 

 

 

Date of Birth:

 

 

 

 

 

 

 

 

 

 

Birthplace:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Social Security Number:

 

 

 

Marital Status:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ethnicity:

 

 

 

 

 

 

 

 

 

Religion:

 

 

 

 

 

 

Highest Grade Completed:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Referring Person:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Referral Agency:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Zip Code:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mandated Client/OR Involvement With: (Check all that apply)

 

 

 

 

No mandates for this client

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Legal/Criminal

 

 

Social Services/MAAT

 

 

Family Court/CPS

 

 

 

 

 

 

Job

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mandating Agency:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contact Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

Client has current significant health issues (note below)

 

 

Client has current psychiatric issues (note below)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Diagnosis:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current Medications:

Substance Abuse Diagnosis (Active in the past six months):

Substance/Dependency or Abuse

Frequency/Amount

Date of Last Use

 

 

 

 

 

 

 

 

 

 

 

 

Client is a registered sex offender:

Yes

No

TRS-48 (9/09)

Financial Information

Employment Status:

 

Unemployed

 

 

Part-time

 

 

Full-time

 

Disabled

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Position:

 

 

 

 

 

 

 

 

 

Annual Gross Income:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No income

 

Other income:

 

 

Public Assistance

 

 

SSI

 

SSD

 

Unemployment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Disability Benefits

 

 

Pension

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical Insurance Information

 

 

 

No Health Insurance

Has Health Insurance

 

Name of Insurance Company

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ID #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is there an Inpatient Rehab Rider?

 

Yes

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

If yes, has pre-certification been obtained?

Yes

 

No

Pre-Certification #:

 

If there is an Inpatient Rehab Rider, the insurance company must be contacted by the client to request the list of network providers. A network provider is where the insurance company will cover the cost of inpatient rehab. If Stutzman ATC is one of the network providers, prior authorization from the insurance company MUST be obtained before being admitted.

If there is no rider, the client will pay for treatment based on GAHI (gross annual household income) and number of people in the household. To receive this information, the client or client’s parent(s) need to contact the INSURANCE/BILLING DEPARTMENT AT (716) 882-4900, EXT. 228. The income must be verified by submitting copies of either check stubs or W-2’s.

If no insurance, has DSS Application been initiated?

Yes

No Appointment Date:

 

 

 

 

 

Medicaid Number

 

 

 

 

 

 

Managed Care Company

Name of Managed Care Company

 

 

 

 

 

Family Health Plus

 

 

 

 

 

For additional information regarding Stutzman, please refer to the following documents:

 

ｸ

Stutzman Brochure

 

 

ｸ

Tips Sheet

 

 

ｸ

Weekly Schedule Sample

Additional Copies of This Form Can Be Obtained at

http://www.oasas.state.ny.us/atc/stutzman/admission.cfm

TRS-48 (9/09)

Form Trs 48 isn’t the one you’re looking for?

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