Therapeutic Group Home Transfer Form

State of Montana Children’s Mental Health Bureau

Therapeutic Group Home Transfer Form

(To be completed within one business day of transfer)

Please type or print clearly. All fields must be entered.

Processing may be delayed if information submitted is illegible or incomplete

Children’s Mental Health Bureau 406-444-4545

Youth Information

NAME: / birthdate:
SSN: / MEDICAID NUMBER:
Transfer date: / Transferred From:
Transferred To:
Reason for Transfer: / *CUSTODIAN MUST BE NOTIFIED AND AGREE TO TRANSFER

Provider Information

/
Provider NAME: / Provider ID number:
NAME of Person submitting form: / phone number: / Fax NUMBER: / email:
ADDRESS: / CITY: / STATE: / ZIP:

Custodian/Guardian Information

/
NAME: / PHONE:
ADDRESS: / CITY: / STATE: / ZIP:
CUSTODIAN/GUARDIAN: ☐ PARENT/LEGAL GUARDIAN ☐ CHILD AND FAMILY SERVICES ☐ TRIBAL SOCIAL SERVICES/BIA ☐ TURNED 18 ☐ OTHER:
Other involvEment: ☐ Involvement with Juvenile Justice (Probation or Corrections) in the past 6 months
☐ Involvement with CFSD in Past 6 months

*The Responsible Party is the person authorized to consent for medical/psychiatric treatment and involved in the discharge plan.

Transmit form to CMHB by ONE of the following

·  Fax: 406-444-6864.

·  E-Pass: State's File Tranfer Service at https://transfer.mt.gov/ to DO NOT SEND THROUGH REGULAR E-MAIL AS IT IS NOT SECURE

·  Mail: to Department of Public Health and Human Services, Developmental Services Division, Children’s Mental Health Bureau, 111 N. Sanders Rm 307, PO Box 4210, Helena, MT 59604-4210

Department of Public Health and Human Services ♦ Developmental Services Division ♦ Children’s Mental Health Bureau

111 N. Sanders Rm 307 ♦ PO Box 4210 ♦ Helena, MT 59604-4210 ♦ Voice: 406-444-4545

11/17/2017