Date: 		

Consumer Name:	Gender: □ Male □ Female □Transgender Current Address 		 Marital Status: □ Single □ Married □ Domestic Partner □ Divorced □ Widowed
D.O.B.: 		Social Security Number 	

Income Source	Amount	MaineCare Number: 	

Maine Care Status: □ Categorical □ Non- Categorical □ Applied/Pending	(date applied)
□ Spend Down 	(amount) 	(deductible dates) □ Other Insurance Housing Subsidy (BRAP, Shelter + Care, Section 8)?		No/ Applied-Pending 	(Date)
Referral Source:	Phone:	Contact Person:  	

Referent E Mail Address:  	

Consumer Area Housing Preference (check all that apply):
☐ Aroostook     ☐ Hancock     ☐ Washington     ☐ Penobscot     ☐ Piscataquis     ☐ Kennebec
☐ Somerset     ☐ Knox     ☐ Lincoln     ☐ Sagadahoc     ☐ Waldo     ☐ Androscoggin     ☐ Franklin
☐ Oxford     ☐ Cumberland     ☐ York

Referral is for (Primary PNMI program choice):	(Secondary Choice)  	

Reason for referral:

Does the consumer have any special considerations/needs/accommodations to be considered for this referral?
□	Yes	□ No
If yes, please note: □ Awake night staff  □1:1  □ handicap accessible  □ medical monitoring
□	other  	

Please note any prior living arrangements and/or periods of homelessness. What worked? What didn’t?

Does the consumer require ADL assistance:	□ Yes □ No
If yes, explain:  	

Current Resources/Supports:
Does the consumer have a guardian? □ No □ Public □ Private □ Under Study
Is the guardianship □ Full □ Limited Explain:  		 Guardian contact first and last name: 		 Guardian Telephone Number:   	
Does the consumer want the services being requested? □ Yes □ No
If no, please explain: 	

Does the consumer have a Rep Payee? □ Yes	□ No
If yes, contact first and last name:  		 Rep Payee Telephone Number:  	

Does the consumer have a case manager? □ Yes □ No
If yes, case manager first and last name: 		 Case Management Agency and Telephone Number:  	

Does the consumer have a Primary Care Physician? □ Yes □ No
If yes, name of Primary Care Physician:  	  PCP Telephone Number  	

Family and/or Other Supports (any other pertinent psychosocial information):

What has family involvement been with consumer?
□Phone	□Visits	□ Treatment Sessions	□ Other	□ Consumer Refuses	□Other

Is there a current contact person? (please list name and telephone number): 	

LEGAL ISSUES:
Does the consumer have any current legal issues/charges?	□ Yes □ No
If yes, explain: 	

Does the consumer have any past legal issues?	□Yes □ No
If yes, explain:	

Is the consumer involved with pre-trial? □ Yes □ No
Does the consumer have a probation officer? □ Yes □ No
If yes, probation officer name: 	Telephone Number: 	 Does the consumer have conditions of release? □ Yes □ No
If yes, explain?  	

DIAGNOSIS
Primary Diagnosis:                                                                 

Secondary Diagnosis:  	                               
Other Diagnoses: 	                                   	
    Current LOCUS Score: 	
Date Diagnosed: 	Name and License Level of Diagnostician:  	 CURRENT SYMPTOMS: 		

Suicidal?	Y□    N□ If Yes, □Ideation □Plan □Means □Intent □Attempt □Hx of Attempts Homicidal?	Y□	N□ If Yes, □Ideation □Plan □Means □Intent □Attempt □Hx of Attempts Psychosis?	Y□	N□ If Yes, □Delusional □Paranoid □Unable to Care for Self □Other Hallucinations?  Y□	N□ If Yes, □Auditory □Visual □Tactile □Olfactory
Depressed?	Y□	N□ If Yes, check signs/symptoms: □Eating □Sleeping □Energy □Isolation
                             □Weight Gain □Other somatic or vegetative symptoms
Are there other areas of risk not previously noted, such as elopement, self-injurious or assaultive behavior that would be helpful to know?  	

Does the Consumer have any current Substance Abuse or Dependence Issues? □ Yes	□ No If yes, please check all that apply:
□	Alcohol	□ Cocaine/Crack	□ Marijuana □ Ecstasy	□ Over the Counter meds
□	Sedatives/Hypnotics  □Opiates/Pain Killers (Heroin, Methadone, Oxycontin, Oxycodone, etc.)
□ Tobacco  □ Caffeine  □ Amphetamine/Methamphetamine □ Benzodiazepines
□	Other Street Drugs	□Other:   	

Dates of onset? 	Current Amounts? 	  Dates of last use/remission? 		 Other Pertinent Substance Use or Dependence History: 	 

CURRENT AND PRIOR TREATMENT (Mental Health and/or Co-Occurring): Inpatient (please note name of hospital and dates):

	Office of Substance Abuse and Mental Health Services
PNMI REFERRAL/APPLICATION 

Outpatient (please note agency name, provider names, and dates):

	

Other:  	

MEDICAL HX AND UPDATES (include relevant lab work and any known allergies):

Has this person ever had a brain injury: □ Yes □ No
If yes, please explain: 	

Does this person have a history of intellectual disability or cognitive challenges? □ Yes □ No
_________________________________________________________________________________________
Medications (both psychiatric and medical/please note current / any recent changes/who prescribes the medications):	

Baseline behavior? How do you know when the client is doing well? Hobbies? Interests? 	

Education History and Current Status: 	

Vocational History and Current Status: 	

Please list any recent and pertinent assessments that have been done within the past three to six months such as Occupational Therapy, Neuropsychological, Psychosexual, or Psychiatric, or Psychological, including dates and assessor contact information or other relevant information.

To keep this application ACTIVE, please call (as provider or as client) to check in every 90 days. This referral will be considered INACTIVE if no contact (email, call or fax) is made by provider or client with SAMHS to follow up on this application.

Office of Substance Abuse and Mental Health Services
PNMI REFERRAL/APPLICATION 
                                              Below is the quoted MaineCare rule for Medical Necessity:
10-144 Chapter 101 Department of Health and Human Services MAINECARE BENEFITS MANUAL Chapter II
Section 97 PRIVATE NON-MEDICAL INSTITUTION SERVICES ESTABLISHED

97.02-2 Medical Necessity Services in PNMIs must be medically necessary, as evidenced by meeting the medical eligibility criteria set forth in this section. A physician or primary care provider must also document in writing that this model of service is medically necessary for the member, and both the physician and the PNMI provider must keep this documentation in the member’s file. For all PNMI services, this documentation must be completed as part of the prior authorization process conducted by the Department and/or its Authorized Agent.

Additional PNMI Provider Requirements:
Accept all Referrals from the Department, in writing to SAMHS staff, within three (3) business days of receipt of Referral.  

Note: Section 277 of the Bates v. DHHS Consent Decree (Consent Decree) does not allow for the denial of a Referral without the Department’s approval.  Any such denial, which has not been approved, is a violation of this Agreement and may result in termination of this Agreement.

Contact the individual being Referred and/or the legal guardian within seven (7) business days of receipt of this Referral. Confirm in writing to SAMHS Residential Team, once contact with individual and/or legal guardian has been made. Admit all individuals to the PNMI within thirty (30) calendar days of the receipt of Referral.

CONSENT DECREE COMPLIANCE REFERRAL FORM:

Client Referred: 
Primary Service Provider Agency Name (Referred to): 
Name of Residential Treatment Facility, If Applicable: 
Address of Discharge Location: 
Contact Name:	
Contact E-mail:
Contact Phone #: 
	
☐ Accepted     Start Date: 
☐ Accepted with requested accommodation(s)   Start Date:   
Accommodation(s) requested:  

☐ Declined or cannot accept     Decline Date:
	Reason:
	☐ Hospital determined patient not ready
	☐ Patient refused
☐ Facility is already 100% occupied (no vacancies)
☐ Other: __________________________________ 
PLEASE FAX THIS PROMPTLY TO:
287-7056 SAMHS

   Which DHHS office(s) should help you? Please check.
□	Office of MaineCare Services	X Substance Abuse and Mental Health Services	
•	Office for Family Independence and Medical Review Team	•	Office of Child and Family Services	
•	Maine Center for Disease Control and Prevention	•	Office of Aging and Disability Services	
•	Dorothea Dix Psychiatric Center	•	Office of Administrative Hearings	
•	Riverview Psychiatric Center	•	Other:	
Whose information is being released? Please print clearly.
Individual’s Name		Date of Birth	Social Security #	
Home Address	Town/City	State	Zip Code	
Telephone
(	)	-	Email address	
               @		

What information should DHHS release? Please check all that apply.
General permission:

X All health information from the DHHS office(s) checked above
•	Claims or encounter data (information about visits to health care providers)
•	Billing, payment, income, banking, tax, asset, or data needed to see if you qualify for DHHS program benefits
•	Limit to the following date(s) or type(s) of information: (for example “Lab test dated June 2, 2017” or “Claims from 2015- 2017”)

•	Other: 		Special permission: Drug/Alcohol Referral or Services

•	Include all drug/alcohol information in the release
•	Include only the specific drug/alcohol records checked:

•	Diagnosis and treatment
•	Clinical notes and discharge summaries
•	Drug/Alcohol history or summary
•	Payment or claims information
•	Living situation and social supports
•	Medication, dosages or supplies
•	Lab results
•	Other:  		
Special permission: Mental/Behavioral Health Services

•	Include this information in the release

•	I want to review my mental health/behavioral health record before release. I understand that the review will be supervised.

Please note: Maine law allows us to share this information with other health care providers and health plans to coordinate your care (to help take care of you) so long as we make a reasonable
effort to notify you of the release.	Special permission: HIV/AIDS Status/Test Results

•	Include this information in the release

Please note: Maine law requires us to tell you of possible effects of releasing HIV/AIDS information. For example, you may receive more complete care if you release this information, but you could experience discrimination if your data is misused. DHHS will protect your HIV data, and all your information, as the
law requires.	

Are you asking DHHS to send your information by EMAIL? r Yes.  r No
Although DHHS has privacy and security protections for my information, I understand that email and the internet have risks that DHHS cannot control. It is possible that my emailed information could be read by a third party. I ACCEPT THOSE RISKS and still ask DHHS to send my information by email. INITIAL HERE  		
Where should DHHS send your information by email? Please print the email address clearly:	

What is the purpose of the release? Please check or write a response.

•	To coordinate or manage my care r For a legal matter, including to provide testimony
•	A personal request rTo see if I qualify for benefits or insurance r Other  	

Please check and print clearly below: rSend my information to rGet my information from:

Name  Address
City, State, Zip Code

Phone	Fax No.	 Name
 Address
 City, State, Zip Code

 Phone	Fax No.	

I understand and agree that:

•	“Information” may be in written, spoken and/or electronic format.

•	This form will expire one year from the date below unless I revoke (take back) my permission sooner.

•	To take back my permission, I will fill out the Revocation Form found at http://www.maine.gov/dhhs/privacy/index.shtml and send it to the office where I receive services. It will not apply to the information that DHHS already released with my permission.

•	If I take back my permission or refuse to release some or all of my information, my choice could lead to an improper diagnosis or treatment, o r denial of insurance coverage.

•	I permit the people and/or offices listed on this form to speak to each other for the purpose(s) on this form.

•	Health information from other providers (such as doctors, hospitals, and counselors) in my DHHS file is included in this release.

•	Unless I am applying for benefits, DHHS will not base my treatment, payment for services, or benefits on whether I sign this form.

•	DHHS offices will keep my information confidential as required by law. If I choose to share my
information with others who are not required by law to keep it private, it may no longer be protected by federal confidentiality laws.

•	If alcohol or drug treatment or program (substance use disorder) records are included in this release, DHHS will include a notice saying that such information may not be re-released or shared without my written permission.

I am signing this form voluntarily. I have the right to a signed copy of this form if I request one.

Date: 	Signature 	

Personal Representative’s authority to sign:  _______________________________

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