Form Trs 48 – Fill Out and Use This PDF

The Form Trs 48 is a document that a company needs when it goes through bankruptcy. It contains information about the business and its assets, liabilities, and creditors.

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Form Trs 48 PDF 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.

Question	Answer
Form Name	Form Trs 48
Form Length	2 pages
Fillable?	Yes
Fillable fields	103
Avg. time to fill out	21 min 10 sec
Other names	TRS 48 stutzman referral form

12

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)

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stage 1 to filling in Form Trs 48

Write down the requested particulars in the segment Age, DateofBirth, Birthplace, Social, Security, Number Marital, Status Ethnicity, Religion, Highest, Grade, Completed Referring, Person Referral, Agency Address, Telephone, Number Zip, Code No, mandates, for, this, client and Legal, Criminal

Filling out Form Trs 48 stage 2

Jot down the vital details as you are on the Frequency, Amount Client, is, a, registered, sex, offender Yes, TRS, and Date, of, Last, Use segment.

stage 3 to filling out Form Trs 48

Within the box Employment, Status Unemployed, Part, time Full, time Disabled, Financial, Information Employer, Position, Annual, Gross, Income No, income Other, income Public, Assistance SSI, SSD, and Unemployment, describe the rights and obligations of the sides.

Entering details in Form Trs 48 stage 4

Finish by checking the next sections and completing them as required: No, Appointment, Date Medicaid, Number Managed, Care, Company NameofManaged, Care, Company and Family, Health, Plus

part 5 to filling out Form Trs 48

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