Authorization Request for
New In/Outpatient Chemical Dependency Services

Click here to open and print or save the Authorization Request for New In/Outpatient Chemical Dependency Services form.

This request is to only be used for NEW IN/OUTPATIENT CHEMICAL DEPENDENCY SERVICES for a client. To report a client's CD treatment progress, please use the "Chemical Dependency Progress Report" form, 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

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