San Francisco Department of Public Health Community Behavioral Health Services

Community Programs Placement 2712 Mission Street San Francisco, CA 94110 (415) 401-2638 General Questions (415) 401-2629 Placement Fax

Behavioral Health Access Center (BHAC) 1380 Howard St. 1st Fl Ste., 100 San Francisco, CA 94103 (415) 503-4730 – Main Number (415) 255-3629 BHAC FAX

Placement Authorization Request Form

Client Name (AKA if known) SSN DOB BIS Number (if available) Program client is currently at Provider RU# (if known) Is Client a SF resident? Yes No Where was client last 30 days? Entitlements: Medi-cal Medicare SSI Other Income Source: Conservator Status: T-Con Permanent LPS Probate Conservator Name: SPR CLIENT: Yes No Pending PLEASE NOTE, IF SPR CLIENT, APPROVAL IS REQUIRED SPR Clinician Tel: HAS ICM: Yes No Pending ICM Clinician Tel: Level of Care Requested: DSM IV-TR Diagnoses: Clinical Indications for Level of Care Request Recommended Treatment Goals: Submitted By: Date: Telephone #: Fax #:

PLACEMENT RECOMMEDATIONS PLACEMENT AUTHORIZED

Dual Dx Res Transitional Res LSAT Clay/Loso Our House RCF/E Med Supported Detox

AOD Social Model Detox AOD Social Model Res Co-Op Support Service Hotel Hotel

Specify

NOT AUTHORIZED REASON: Authorizing Clinician Date

Authorizer Form Rev: 08/17/10