Log Medical Record Dates
Please insert the lmeacrn of your client
Triage (mm/dd/yyyy)
Referral Date (mm/dd/yyyy)
Consumer Contact (mm/dd/yyyy)
Appointment Date (mm/dd/yyyy)
Mental Health Assessment (mm/dd/yyyy)
Consumer Qualified for Services (mm/dd/yyyy)
Documentation/Paperwork Completed for Medical Records (mm/dd/yyyy)
PCP Completed (mm/dd/yyyy)
ITR Completed (mm/dd/yyyy)
Submission to Value Options (mm/dd/yyyy)
Authorization Approval (mm/dd/yyyy)
Start Date of Service (mm/dd/yyyy)
Total Business Days Before Service Begins