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Dates of Service Codes Requested Units Requested Request Sent By Phone Total Pages Faxed U7834 Page 1 of 3 SERVICE TYPE FOR MENTAL HEALTH Select applicable ARMHS Eating Disorder Residential CTSS IOP DBT Children s Mental Health Residential Treatment IRTS Cognitive Rehabilitation Inpatient Mental Health Admission Crisis Residential Partial Hospitalization Day Treatment Transcranial Magnetic Stimulation Confirm and attach the following REQUIRED DOCUMENTATION Diagnostic Assessment Functional...
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