Authorization Request for
Chemical Dependency Evaluation
Click here to open and print or save the Authorization Request for Chemical Dependency Evaluation form.
This request is to only be used for CD EVALUATION ONLY. To request inpatient or outpatient CD treatment, please use the "Authorization Request for New In/Outpatient Chemical Dependency Services" form 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
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