Representative Payee Program Self Referral Form (Page 2 of 2) in pdf

Representative Payee Program Self Referral Form Page 2

MHA Form I - A

Last Updated Aug 2015 - LB

Please list all individuals and/or programs you have asked to be your payee prior to

contacting MHA of Butler County:

Name

Relationship

Contact Number

PSYCHIATRIC AND D & A INFORMATION:

Primary Diagnosis: ______________________________________________________

Secondary Diagnosis: ____________________________________________________

Are you currently in treatment? ________ Yes _______ No

If yes, with whom:_____________________________________________________________

Are you open with case management services? _______ Yes _______ No

If yes please complete:

Case Manager Name

Agency

Phone Number

IT IS UNDERSTOOD BY THE CONSUMER:

All referrals may be placed on a waiting list until an opening with a representative payee

becomes available.

PLEASE MAIL OR FAX TO:

Mental Health Association

140 North Elm Street

Butler, PA 16001

Attn: Amber

FOR ALL NEW REQUEST INCLUDE DOUBLE SIDED SSA DOCTOR’S PRESCRIPTION TO

HAVE PAYEE COORDINATOR ALONG WITH THIS FORM

ALL REQUESTS REQUIRE A COPY OF SSA – 787 TO PROCESS APPLICATION

For Internal Use Only:

Date application received:_____________

Meets BCHS requirements for service: ______ Y or _______ N

Please list documentation or information still needed:

Representative Payee Program Self Referral Form Page 2