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Click ‘Get Form’ to open the abp 1676 3 in the editor.
Begin with Section 1, where the patient/client must provide their name, sex, birth date, and last four digits of their social security number. Ensure all fields are accurately filled out.
In Section 2, a licensed mental health professional should answer questions regarding the patient's mental health condition. They need to indicate if there is any impairment that limits life activities and provide details on the onset date of the condition.
The provider must also confirm if the patient is actively seeking treatment and estimate how long the condition is expected to last. This information is crucial for evaluating eligibility for assistance.
Finally, in Section 3, the provider must sign and print their name along with their license number and contact information. Make sure this section is completed before submitting.

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