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The TRS 48 form plays a critical role in facilitating admissions to the Stutzman Addiction Treatment Center. Designed to collect essential client information, the form covers various facets such as personal details, health status, financial background, and referral specifics. It includes fields for the client’s name, contact information, and demographics while also accounting for their medical and psychiatric history. Notably, the form requires details regarding substance use and related diagnoses, which are crucial for determining the appropriate treatment plan. Financial details are outlined, including employment status and insurance coverage, making it clear whether pre-certification is necessary for admitted clients. The process also involves collaboration with referral agencies and mandates that may impact the client’s treatment path. Proper completion of the TRS 48 not only streamlines the admissions process but also ensures that clients receive tailored care based on their unique circumstances. Understanding and effectively utilizing this form is essential for both clients and referring professionals, helping to set the stage for successful treatment experiences.

Trs 48 Example

PATIENT NUMBER:

SCHEDULED ADMISSION DATE:

STUTZMAN ADDICTION TREATMENT CENTER

CLIENT REFERRAL FORM

Fax this form, psychosocial assessment, medical information, and any recent lab work to:

ADMISSIONS OFFICE FAX NUMBER (716) 882- 4542.

After faxing the requested information, please call (716) 882-4906 for an admission date.

Client Information

Sex:

 

 

 

Male

 

 

 

Female

 

 

Transgender

 

 

 

Veteran:

 

 

Yes

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Client Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

County:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No Permanent Address

 

 

 

 

No Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Full Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Town/City/State:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Zip Code:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone Number:

 

 

 

 

 

 

OR

 

Contact Number :

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Age:

 

 

 

Date of Birth:

 

 

 

 

 

 

 

 

 

 

Birthplace:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Social Security Number:

 

 

 

Marital Status:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ethnicity:

 

 

 

 

 

 

 

 

 

Religion:

 

 

 

 

 

 

Highest Grade Completed:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Referring Person:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Referral Agency:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Zip Code:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mandated Client/OR Involvement With: (Check all that apply)

 

 

 

 

No mandates for this client

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Legal/Criminal

 

 

Social Services/MAAT

 

 

Family Court/CPS

 

 

 

 

 

 

Job

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mandating Agency:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contact Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

Client has current significant health issues (note below)

 

 

Client has current psychiatric issues (note below)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Diagnosis:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current Medications:

Substance Abuse Diagnosis (Active in the past six months):

Substance/Dependency or Abuse

Frequency/Amount

Date of Last Use

 

 

 

 

 

 

 

 

 

 

 

 

Client is a registered sex offender:

Yes

No

TRS-48 (9/09)

Financial Information

Employment Status:

 

Unemployed

 

 

Part-time

 

 

Full-time

 

Disabled

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Position:

 

 

 

 

 

 

 

 

 

Annual Gross Income:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No income

 

Other income:

 

 

Public Assistance

 

 

SSI

 

SSD

 

Unemployment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Disability Benefits

 

 

Pension

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical Insurance Information

 

 

 

No Health Insurance

Has Health Insurance

 

Name of Insurance Company

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ID #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is there an Inpatient Rehab Rider?

 

Yes

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

If yes, has pre-certification been obtained?

Yes

 

No

Pre-Certification #:

 

If there is an Inpatient Rehab Rider, the insurance company must be contacted by the client to request the list of network providers. A network provider is where the insurance company will cover the cost of inpatient rehab. If Stutzman ATC is one of the network providers, prior authorization from the insurance company MUST be obtained before being admitted.

If there is no rider, the client will pay for treatment based on GAHI (gross annual household income) and number of people in the household. To receive this information, the client or client’s parent(s) need to contact the INSURANCE/BILLING DEPARTMENT AT (716) 882-4900, EXT. 228. The income must be verified by submitting copies of either check stubs or W-2’s.

If no insurance, has DSS Application been initiated?

Yes

No Appointment Date:

 

 

 

 

 

Medicaid Number

 

 

 

 

 

 

Managed Care Company

Name of Managed Care Company

 

 

 

 

 

Family Health Plus

 

 

 

 

 

For additional information regarding Stutzman, please refer to the following documents:

 

Stutzman Brochure

 

 

Tips Sheet

 

 

Weekly Schedule Sample

Additional Copies of This Form Can Be Obtained at

http://www.oasas.state.ny.us/atc/stutzman/admission.cfm

TRS-48 (9/09)

Form Characteristics

Fact Name Details
Form Purpose The TRS-48 form is used for client referrals to the Stutzman Addiction Treatment Center.
Fax Submission This form must be faxed to the Admissions Office at (716) 882-4542.
Contact for Admission Call (716) 882-4906 to obtain an admission date after faxing the required documents.
Client Information Required Includes details such as name, age, address, and contact information.
Health Issues Disclosure Clients must disclose significant health and psychiatric issues on the form.
Financial Information Employment status, income, and insurance information are necessary for processing.
Insurance Requirements If applicable, pre-certification from the insurance company must be obtained before admission.
Eligibility for Treatment Clients with no insurance will have treatment costs determined by their gross annual household income.
Documentation Availability Additional copies of the TRS-48 form can be obtained online at the designated OASAS website.

Guidelines on Utilizing Trs 48

The Trs 48 form is essential for the admission process to Stutzman Addiction Treatment Center. Follow the steps below to complete it accurately and ensure a smooth application experience.

  1. Gather necessary documents: Obtain psychosocial assessments, medical information, and recent lab work.
  2. Locate the Patient Number and fill in the Scheduled Admission Date.
  3. Enter the Client Information:
    • Select the client's sex and veteran status.
    • Fill in the client's full name, county, address, and telephone number.
    • Provide the client’s age, date of birth, birthplace, and social security number.
    • Include marital status, ethnicity, religion, and highest grade completed.
  4. Complete the Referring Person section: Enter the name, telephone number, and referral agency details.
  5. Indicate any mandates applicable to the client by checking the appropriate boxes.
  6. Document any current health or psychiatric issues by noting them below the respective section.
  7. Fill out the sub-section for Diagnosis and Current Medications.
  8. Provide details about Substance Abuse:
    • List the substance, frequency/amount, and date of last use.
  9. State whether the client is a registered sex offender.
  10. Complete the Financial Information section by specifying employment status and income details.
  11. Fill in the Medical Insurance Information section:
    • Specify if the client has health insurance.
    • If applicable, provide the name of the insurance company and ID number.
    • Indicate if there is an inpatient rehab rider and its pre-certification status.
  12. If there is no insurance, indicate whether a DSS application has been initiated.
  13. Review all entries for accuracy before submission.

Once completed, fax the form along with required documentation to the admissions office. After faxing, call the specified number to arrange an admission date.

What You Should Know About This Form

What is the TRS 48 form used for?

The TRS 48 form serves as the Client Referral Form for Stutzman Addiction Treatment Center. It collects essential information about a potential client, such as their personal and health details, as well as their financial situation and insurance coverage. This information is crucial for determining eligibility and processing an admission into the treatment program.

How do I submit the TRS 48 form?

To submit the TRS 48 form, you need to fax it along with the psychosocial assessment, medical information, and any recent lab work to the Admissions Office at (716) 882-4542. Once you have sent the materials, it is important to follow up by calling (716) 882-4906 to schedule an admission date.

What information is required on the TRS 48 form?

The TRS 48 form requires various pieces of information, including the client’s personal details (like their name, address, age, and contact number), health information (current medications, health issues, and substance use history), as well as financial and insurance details (employment status, income, and health insurance coverage). This comprehensive data assists in the effective assessment and treatment planning for the client.

What should I do if the client has no health insurance?

If the client does not have health insurance, it is necessary to confirm whether an application for assistance has been initiated with the Department of Social Services (DSS). This can help the client secure necessary financial support for their treatment. Mark the “No Health Insurance” section on the form and indicate if a DSS application has been started.

What information do I need to provide regarding the client’s financial status?

When filling out the TRS 48 form, you must provide details about the client’s employment status, annual gross income, and any other sources of income, including public assistance or disability benefits. If applicable, you will need to supply documentation, such as paycheck stubs or W-2 forms, to verify the income reported.

What if the client is a registered sex offender?

The form includes a section where you can indicate whether the client is a registered sex offender. This is an important consideration in the admission process and will be taken into account when assessing the client’s needs and treatment plan.

What are the implications of having an Inpatient Rehab Rider with my insurance?

If the client has an Inpatient Rehab Rider as part of their health insurance, it is necessary to contact the insurance company to obtain a list of network providers. Should Stutzman Addiction Treatment Center be on that list, prior authorization must be secured from the insurance company before the client's admission. Failing to do so may result in financial responsibility falling to the client for the treatment costs.

Where can I find additional information about Stutzman Addiction Treatment Center?

For more in-depth information about Stutzman Addiction Treatment Center, you can refer to the Stutzman Brochure, Tips Sheet, and Weekly Schedule Sample. Additional copies of the TRS 48 form and resources can be accessed through the official website: Stutzman Admission Information.

Common mistakes

Completing the TRS 48 form is critical for obtaining the services needed at the Stutzman Addiction Treatment Center. However, many individuals make common mistakes that can hinder the processing of their application. One major error occurs when fields are left blank. Each section requires specific information, and missing data can lead to delays. Always ensure that every required field is filled out completely.

Another frequent mistake is providing outdated or incorrect contact information. This can result in a loss of communication between the treatment center and the client. Using the most current phone numbers and addresses is vital for receiving timely updates regarding admission dates and requirements. Additionally, failing to include the correct patient number can complicate the process, as it ties your application to your medical records.

In the financial information section, individuals often underestimate their annual gross income. Being accurate with income details is crucial, as it affects eligibility for assistance. Underreporting income can lead to unexpected costs if the treatment is not adequately covered. Furthermore, neglecting to indicate whether the client has Medicaid or other health insurance can result in unnecessary complications, as the admissions office may assume that the client is uninsured.

Another common error involves misunderstanding the requirements regarding insurance. Some individuals mistakenly believe that having health coverage guarantees automatic admission. In reality, if an inpatient rehab rider is not available, clients might have to financially plan differently. Ensuring that pre-certification has been obtained is also necessary; skipping this step can prevent access to the required services.

Moreover, a lack of attention to the current health issues can be detrimental. This form has spaces to mention significant health problems and psychiatric issues. Overlooking this information can diminish the treatment plan's effectiveness and possibly lead to serious health risks. Always take the time to note such conditions thoroughly.

Incomplete information about current medications is another pitfall. The treatment team needs a complete picture of what the client is taking to provide effective care. Clients often forget to list all medications, which can compromise their safety during treatment.

Another mistake is failing to indicate involvement with mandated agencies. In the section that asks if there are any mandates for the client, many forget to check the appropriate boxes. Identifying these mandates helps the treatment center coordinate with necessary agencies effectively.

Age and date of birth can sometimes be mishandled as well. Providing inaccurate dates can lead to administrative errors, which may affect eligibility in certain situations. Therefore, it’s essential to double-check this crucial information.

Finally, not following up after faxing the form is a common oversight. Once you send the TRS 48 form, making a phone call to confirm its receipt is equally important. This ensures that all materials have reached the admissions office without any issues.

Avoiding these mistakes will help ensure that the process is smooth and efficient, paving the way for a successful admission into the Stutzman Addiction Treatment Center.

Documents used along the form

The TRS 48 form is an important document used at Stutzman Addiction Treatment Center for client referrals. Alongside this form, several additional documents play a crucial role in the admissions process. Below is a list of four commonly used documents that may accompany the TRS 48 form.

  • Psychosocial Assessment: This document provides a detailed overview of the client's personal history and current psychological status. It includes information about the client’s social environment, relationships, and mental health background.
  • Medical Information: This form contains critical details regarding the client's medical history, including any previous treatments, chronic health issues, and current medications. This information is essential for assessing the client’s overall health prior to admission.
  • Recent Lab Work: Copies of recent laboratory results may be required to evaluate the client's current health status. This includes tests related to substance use or other significant health concerns that could impact treatment.
  • Insurance Verification Form: If the client has insurance, this document confirms coverage details pertinent to treatment. It includes information about the insurance provider, type of coverage, and any required pre-certification for services.

Understanding these documents ensures a smoother admission process and helps facilitate timely treatment for clients seeking assistance at the Stutzman Addiction Treatment Center.

Similar forms

  • Client Intake Form: Similar to the TRS 48 form, a client intake form collects personal and demographic information needed for treatment services. This document typically includes contact details, medical history, and necessary referrals.
  • Referral Form: A referral form serves as a method to transfer a client from one provider to another. Like the TRS 48, it often contains client identification and relevant health information to ensure continuity of care.
  • Psychosocial Assessment: This assessment evaluates the social and psychological needs of a client. It parallels the TRS 48 in that it gathers detailed information regarding the client's background, including mental health history and support systems.
  • Insurance Verification Form: This document confirms a client’s insurance coverage, similar to the TRS 48. It typically requests details about insurance status, policy numbers, and whether pre-certification is necessary for treatment.
  • Medical History Form: A medical history form documents a client's past and present health issues. Similar to the TRS 48, it requires information on current medications, diagnoses, and any significant health conditions affecting treatment.
  • Financial Disclosure Form: This form outlines a client's financial situation and income sources. Much like the TRS 48, it assesses the client’s ability to pay for services through income verification and public assistance eligibility.
  • Consent for Treatment Form: A consent form is essential for obtaining permission to provide treatment. It resembles the TRS 48 in its requirement for client identification and acknowledgment of the treatment process.
  • Discharge Summary: This document provides a summary of the client’s treatment and progress. Similar to the TRS 48, it may include diagnoses and recommendations for future care, ensuring that vital information is shared post-treatment.
  • Assessment and Treatment Plan: Used by healthcare providers, this document outlines goals for the client’s treatment. Like the TRS 48, it draws from the initial client information to create a tailored plan to address specific health issues.

Dos and Don'ts

When completing the TRS 48 form, it's important to get things right to ensure a smooth admission process. Here are some helpful dos and don'ts to guide you through filling out this important document.

  • Do provide accurate and complete client information, including full addresses and contact details.
  • Do indicate any current health or psychiatric issues clearly.
  • Do check all applicable boxes related to mandated involvement for the client.
  • Do ensure that your insurance information is filled out correctly, including ID numbers and coverage details.
  • Don't leave any sections blank; all information is crucial for the assessment.
  • Don't exaggerate or misrepresent your financial situation; honesty is essential.
  • Don't forget to call the admissions office after faxing to confirm your submission.
  • Don't overlook the need for pre-certification with your insurance provider if required.

By following these simple guidelines, you’ll ensure that you’re on the right path for a successful admission process. Taking the time to fill out the TRS 48 form accurately and completely can make all the difference in your experience.

Misconceptions

  • Misconception 1: The TRS 48 form is only for individuals with health insurance.

    Many people believe that the TRS 48 form is exclusively for those who have health insurance. This is not accurate. The form is accessible to all individuals seeking admission, regardless of their insurance status. If there is no coverage, the client can receive treatment based on their income and household size.

  • Misconception 2: Filling out the TRS 48 form guarantees admission to the treatment center.

    Completing the TRS 48 form does not automatically secure a spot at the Stutzman Addiction Treatment Center. The form is part of the referral process, and it is important to call the admissions office to confirm an admission date after submitting the required documentation.

  • Misconception 3: Personal information on the TRS 48 form is not confidential.

    Some individuals worry that their information will not be kept confidential. In reality, all personal details shared on the TRS 48 form are treated with strict confidentiality. The information is used solely for the purpose of assessing admission eligibility and planning appropriate care.

  • Misconception 4: The TRS 48 form only addresses substance abuse issues.

    While the form does include sections related to substance use, it also incorporates a broader evaluation of the client's mental and physical health. This comprehensive assessment ensures that all relevant health issues are considered and that the treatment plan can be effectively tailored to each client’s unique needs.

Key takeaways

When using the TRS-48 form for admission to the Stutzman Addiction Treatment Center, it's important to keep the following key points in mind:

  • Patient Information Is Crucial: Complete all fields, including the patient’s name, contact details, and identifying information.
  • Referral Process: Fax the completed TRS-48 form along with relevant medical information and lab results to the admissions office at (716) 882-4542.
  • Follow-Up Required: After faxing, it is necessary to call (716) 882-4906 to confirm the admission date.
  • Health Insurance Verification: Determine if the patient has health insurance that covers inpatient rehab and check if a pre-certification has been acquired.
  • Income Verification: Provide documents such as check stubs or W-2 forms to verify the patient's income for treatment cost assessments.
  • Additional Resources: Utilize the Stutzman Brochure, Tips Sheet, and Weekly Schedule Sample for more comprehensive information about the treatment process and services offered.