CDC Requests Now Hiring State-Wide Make A Referral Areas We Serve Frequent Questions Make A Payment Client First Name* (First 5 Letters) Client Last Name* Client Insurance ID* i.e. B12345678, YUQ123456, 003784297Approximate Client Age*Please enter a number from 1 to 105.Action Requested ( Choose One )*CDC 21 - Preadmission AuthorizationAssessment ReviewCDC 23 - Initial Treatment Plan AuthorizationCDC 42 - 6 Month Update AuthorizationDischarge ( Indicate Reason Below )CDC 21 ExtensionCDC 41 Information UpdateConfirmation* I have turned in the updated treatment plan signature page and 6 month surveyTreatment plan signature pages (medicaid only) and 6 month surveys are required for ALL 6 month updates (including STP requests for insurance and private pay clients) - If this is an initial STP request please just check the box. No survey or signature page is needed. Client Current Phone Number*Ensure this is updated in TH alsoClient Current Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Ensure this is updated in TH alsoClient Current Email Address* Ensure this is updated in TH alsoIf you enter the word "unknown" or "n/a" as part of the email address, this form will not process correctly and we will never receive a copy of it. Info Updated* I have updated this information in THI verify that I have updated ThinkHealth with any new demographic information for this client. If nothing has changed, I verify that all information currently listed in ThinkHealth is correct and accurate. Needs Therapist Assigned?* Yes No Location*Tulsa Main OfficeTulsa 41st Street OfficeTulsa Garnette OfficeSouth Tulsa Community HouseBroken ArrowTahlequahPryorOwasso 86th Street North OfficeSapulpaCowetaNormanStillwaterHome / OtherCity (If the city is Tulsa please provide nearest cross streets)* First names and client ID numbers (four digit TH number) of all persons receiving services in this household*Brief description of problem*Reason for Needing an Extension or Information Update*Reason for Discharge*Name of person to contact (plus affiliation to client) and phone number to reach them at*Requested Start Date* MM slash DD slash YYYY Services Requested ( CDC-21 Only)* Individual / Base Psychotherapy Family Psychotherapy Group Psychotherapy Case Management Pay Source/Insurance Provider* Services Requested ( Simple Treatment Plan Only )* Individual / Base Psychotherapy Family Psychotherapy Group Psychotherapy Have you verified with the insurance provider for coverage of family sessions?*Please Select OneYesNoDoes the client have a secondary insurance?* Yes No Name of secondary insurance* Therapist* If unsure enter UNKOWN, if the therapist needs to be assigned enter ASSIGNCase Manager* If unsure enter UNKOWN, if none enter N/AAdditional Information Client Is Homeless Should Be Eligible for Rehab Should Be Eligible for Higher Case Management Need Letter of Termination Need Letter of Collaboration If you are requesting to discharge your client, you do NOT need to fill the form to have the client removed form you chart. We will do that automatically once we process the discharge. Thank you. Requestor's Email Address ( To be emailed a copy of the submission )* Upload page 1 of intake or treatment plan signature pageMax. file size: 50 MB.Not Needed if Paperwork was Completed Electronically. Remember: ALL ORIGINAL DOCUMENTS STILL NEED TO BE SUBMITTED TO MAIN TULSA OFFICECommentsThis field is for validation purposes and should be left unchanged. Δ