SUD Treatment Referral/Admission Form

The format of the admission form has changed.   Fill in the admission date and time, the ‘Time to Treatment’ will prefill in with the appropriate number of days. If ‘Court/criminal justice referral/DUI/DWI’ is selected the ‘Detail Criminal Justice Referral’ dropdown will appear and needs to be completed.

If the time to treatment is over 14 days the following screen will appear. You need to enter a comment to address the delay, such as: No Show or Cancelled: “See Twin 14” – then complete a Twin 14 form with details Client requested services outside the 14 days: Check corresponding box in this section and indicate in the comment box the date your program could have provided an appointment that would be timely. Program did not offer timely appointment: Indicate in the comment section timely appointment was not offered. Remember, programs are contractually required to provide timely services.

The ‘Race/ Ethnic Origin 1’ and ‘Hispanic or Latino Ethnicity’ are required fields.   The tip indicators work when your mouse icon hovers over them. ID/DD defaults to ‘Not Evaluated’ as this is only used when an evaluation for Intellectual/Developmental Disability occurs, based on the Michigan Mental Health Code. MI/SED Designation defaults to ‘Not Evaluated’ as this is only used for evaluation of Mental Illness/Serious Emotional Disturbance for CMH criteria. Integrated Substance Use and Mental Health Treatment – select ‘Yes’ when providing co-occurring treatment services. Both a SUD and MH diagnosis need to be indicated in the diagnostic section of the form. Provider should request the “HH” modifier on the authorization. Correctional/Legal Status s listed from highest to lowest status. Select the highest status that applies.

Pregnancy: Men and children are to be marked ‘N/A’ Pregnancy: Men and children are to be marked ‘N/A’. Only women are marked as ‘Yes’ or ‘No’. Select ‘Yes’ for Women’s Specialty Program if you are providing gender specific programming approved by MCOSA. When ‘Yes’ is select, additional questions will appear and need to be completed. Medication Assisted Opioid Therapy: Hover over the to read the options. ‘Not Applicable’ is answered for any client that does not have opioid use (heroin, other opioid or illicit methadone) listed in the SUD Substances box as a Primary, Secondary or Tertiary substance. If opioid use is listed in the SUD Substance box, indicate ‘Yes’ if methadone, Suboxone or Vivitrol is part of the client’s treatment, whether or not provided at your agency. List the prescribed medication in the text box. Answer ‘No’ if an opioid using client is not receiving methadone, Suboxone or Vivitrol from any provider as part of their treatment.

New - Signatures The new SUD Admission form requires the user to sign the document. A TEDS record will not be created until the SUD Admission form is signed. Enter your password and then select the “Sign and Save” button to complete the form. Clicking the Save button at the bottom of the page only will not save your signature.

Errors in SUD/TEDS Records

SUD Discharge Form Example in the handouts