Chemical Dependency Progress Report

Click here to open and print or save the Chemical Dependency Progress Report form.

This request is to only be used to request ADDITIONAL IN/OUTPATIENT CD TREATMENT SERVICES. If a request is needed for a CD Evaluation or initial authorization for in/outpatient CD treatment, please use the "Authorization Request for Chemical Dependency Evaluation" or "Authorization Request for New In/Outpatient Chemical Services" forms, which can be found at www.team-mn.com.

Please print clearly. Incomplete or illegible forms can not be processed.

Please fax completed forms to TEAM at: 651-642-1809

Adobe's Reader software is required to open this form. If you need the software, it is freely available from Adobe: Adobe Reader