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Online Pre-Authorization Form

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Online Pre-Authorization Form

Gender identity:

Criteria for PRP Uninsured/ State Funded Coverage Questions

Recently Incarcerated?:
Hospitalized for mental health within the last 6 months?:
Placed in a state hospital?:
A RRP (Residential Rehabilitation Service) Bed within the last 6 months?:
Type of Care (PLEASE CHECK ALL THAT APPLY, if qualified):
Any arrest in the past 30 days?:
Currently Employed?:
Veteran?:
In Iraq or Afghanistan?
Is the client eligible for MTA pass?:

Office Use Only:

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