REQUEST FORM (TAR) - Partnership HealthPlan
date to the best of my knowledge, the above information is true, accurate and complete and the requested services are medically indicated and necessary to the health of the patient.
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PHC TAR REQUIREMENTS - Partnership HealthPlan …
www.partnershiphp.orgAttachment A - MCUP3041 Attachment A - MCUP3049 Attachment B - MCUG3007 (TAR to be submitted by the provider performing the service) Revised 06/13/2018 Page 1 of 8
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www.partnershiphp.org• Problem Lists / Medical History • Medication List • 2016-2017 Consultations or referrals to specialists (nephrologist, endocrinologist) • 2016 - 2017 date of eye exam and result, consults, or
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www.partnershiphp.orgInformed Consent for Buprenorphine-Naloxone As a participant in the buprenorphine protocol for treatment of opioid abuse and dependence, I freely and voluntarily agree to accept this treatment agreement/contract, as follows: 1. I agree to keep, and be on time to, all my scheduled appointments with the doctor and his/her assistant. 2.
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