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 |
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Form Name | Form Trs 48 |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names |
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)
Client Information
Sex: |
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Male |
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Female |
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Transgender |
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Veteran: |
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Yes |
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No |
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Client Name: |
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County: |
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No Permanent Address |
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No Phone |
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Full Address: |
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Town/City/State: |
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Zip Code: |
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Telephone Number: |
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OR |
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Contact Number : |
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Age: |
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Date of Birth: |
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Birthplace: |
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Social Security Number: |
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Marital Status: |
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Ethnicity: |
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Religion: |
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Highest Grade Completed: |
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Referring Person: |
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Telephone Number: |
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Referral Agency: |
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Address: |
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Zip Code: |
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Mandated Client/OR Involvement With: (Check all that apply) |
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No mandates for this client |
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Legal/Criminal |
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Social Services/MAAT |
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Family Court/CPS |
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Job |
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Mandating Agency: |
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Contact Name: |
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Telephone Number: |
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Client has current significant health issues (note below) |
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Client has current psychiatric issues (note below) |
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Diagnosis: |
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Current Medications:
Substance Abuse Diagnosis (Active in the past six months):
Substance/Dependency or Abuse |
Frequency/Amount |
Date of Last Use |
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Client is a registered sex offender:
Yes
No
Financial Information
Employment Status: |
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Unemployed |
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Disabled |
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Employer: |
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Position: |
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Annual Gross Income: |
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No income |
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Other income: |
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Public Assistance |
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SSI |
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SSD |
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Unemployment |
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Disability Benefits |
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Pension |
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Other: |
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Medical Insurance Information |
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No Health Insurance |
Has Health Insurance |
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Name of Insurance Company |
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ID #: |
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Is there an Inpatient Rehab Rider? |
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Yes |
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No |
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If yes, has |
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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)
If no insurance, has DSS Application been initiated? |
Yes |
No Appointment Date: |
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Medicaid Number |
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Managed Care Company |
Name of Managed Care Company |
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Family Health Plus |
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For additional information regarding Stutzman, please refer to the following documents: |
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|
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Stutzman Brochure |
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Tips Sheet |
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Weekly Schedule Sample |
Additional Copies of This Form Can Be Obtained at
http://www.oasas.state.ny.us/atc/stutzman/admission.cfm