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Click ‘Get Form’ to open the UC-16Q in the editor.
Begin by entering the Case Number and your Name at the top of the form. Ensure that all personal information is accurate.
Fill in your Social Security Number (SS#) as required. This information is crucial for processing your request.
In the Certification section, provide your name and SSN again, then authorize the Substance Abuse Treatment Professional to release information by signing and dating the form.
Next, have your Substance Abuse Treatment Professional complete their section. They will need to provide details about the treatment facility, type of treatment received, and dates of treatment.
Ensure that they indicate whether you are currently in treatment and if you have successfully completed it. Attach any necessary discharge summaries or treatment plans.
Finally, review all sections for completeness before submitting it back to the appropriate department.
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