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Medicaid Expansion Crisis Line Utilization Form

Please complete the following form for any Medicaid Expansion Member utilizing the Crisis Line to access the Mobile Crisis Team, the Emergency Room or Detox.

Member

* Required fields

Member First Name

Member Last Name

Member Date of Birth

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Member ID Number

Member Phone Number

Case Management Referral Yes

Summary of the Member's Needs

Submitter

Submitter First Name

Submitter Last Name

Submitter Contact Number

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Medicaid Expansion Crisis Line Utilization Form