Brain Rehab Network Admission Request

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Date of request: Click or tap to enter a date.	Requestor:
1. Consumer information
Consumer’s name:
Prime:	DOB:	SPL:
2. Local office staff information
Current CM/TC name:	Branch:
Email:	Phone #:
Receiving CM/TC name:	Branch:
Email:	Phone #:
3. Requestors required actions prior to submissions
By checking the boxes below, the requestor attests all required actions were taken. If a required action was not taken, the request may be returned for completion.

☐ A recent CA/PS has been completed within 30 days of this request.
☐ Reviewed the statement of work for eligibility.
☐ Confirmed admission criteria has been met as outlined in the statement of work.
☐ Provider’s assessment completed and a copy is attached with this request. ☐ Medical documentation supporting diagnosis of disabling brain injury is attached.
☐ A pre-admission conference has been scheduled within 30 days of request with all parties.
☐ Receiving branch (if different) has been notified of pending admission.
☐ Narrated all required actions above were taken in Oregon ACCESS.

4. Central office review
Central Office determination will be made within two business days of receiving the request. Determinations will be narrated accordingly in Oregon ACCESS.
Date Received: Click or tap to enter a date.
Determination:
Reason:
Follow-up action required:
Reviewer name:	Title:
Date: Click or tap to enter a date.

Instructions to complete form:

If requested at the top of this document, click “Enable Content” for the form to work correctly.

Save a blank copy of this form to your computer or drive.

Fill out all areas to the best of your knowledge. If an area is left blank, add details in the submission email as to why it is left blank. (Example: The providers assessment will be sent by the provider directly to Central Office.)

Click “Submit”.

“Submit” will re-save the completed form and then automatically populate the document into Outlook as an attachment with a pre-filled subject line and simple message in the body of the email. If no additional information or documentation is needed for the email at this time the requestor can hit send.

If you are having issues or do not use Outlook do not use the “Submit” button. Instead, save the document and send it as an attachment to the Contract Administrator: jonathan.d.tilford@dhsoha.state.or.us.