CT BHP RE-REGISTRATION/CONCURRENT REVIEW FORM ... 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in the required fields marked with an asterisk (*). Start with the Provider EDS/CMAP ID #, followed by the clinician's name and credentials.
3. Next, enter the Facility/Provider Name and Telephone Number. Ensure you provide accurate service location details.
4. Fill in the Member Name and Medicaid/Consumer ID#, along with their Date of Birth (DOB). Select the appropriate Level of Care from the options provided.
5. For any updates needed, indicate Behavioral Diagnoses and Primary Medical Diagnoses by entering Diagnosis Codes and Descriptions as required.
6. Complete sections on Current Risks and Current Impairments by checking relevant boxes based on assessments. Be thorough to ensure accurate representation of member needs.
7. Finally, review all entries for accuracy before saving or submitting your form through our platform.

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