Issues with treatment plan review: by r16lFE

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									       Office of Child and Family Services Referral Checklist
Please print this form, check and enclose all of the following items from your agency,
and send with referral:

                 DHHS Referral
                 A social summary
                Prior Authorization (if requesting medication or substance abuse
               treatment).
                 Documentation of Guardianship (if other than legal parent)

OCFS Referral Checklist for children in custody:

Enclosed is the necessary Kennebec Behavioral Health admission paperwork to be
completed if guardian for our agency before an appointment can be scheduled. (available
on KBH website documents screen)

      HIPPA Consent for Treatment
      Orientation Manual (attached are required consent forms)
      Kennebec Behavioral Health Release of Information Forms

Choose the office site where the patient will be seen: i.e. Augusta, Skowhegan,
Waterville, or Winthrop.

For each referral, complete releases for each of the following: the Primary Care
Physician, the school attended by the referred child, and one for the child’s parents and/or
foster parents. Please include additional releases for involved treatment providers as
deemed appropriate by the caseworker (i.e. in home supports, or recently involved
hospital).

Once completed, please fax or mail these forms to the appropriate Kennebec Behavioral
Health office site attention “Access Center”:

Augusta: 66 Stone St. Augusta, Maine 04333 or fax to 626-3612.
Waterville and Skowhegan: 67 Eustis Parkway Waterville, Maine 04901 or fax to 877-
8426.
Winthrop: 736 Old Lewiston Road, Route 202 04364-4121 or fax to 377-8564

REFERRAL WILL BE PROCESSED WHEN WE RECEIVE ALL DOCUMENTATION.

If you have any questions, please contact the central Access Office at 1-888-322-2136
Thank you for your assistance.

Sally Chambers
Access Center Coordinator

								
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