As of August 2023, we have added a requirement to include the International Classification of Disease (ICD) code to identify the exact diagnosis so that the receiving provider can enter it correctly into their own electronic health record.
As of September we are also requiring that the clinician identify that they believe the individual can live in the community independently with the support of non-intensive housing supports.
Please ensure the verification section is executed by the licensed clinician.
Falsification of this document can result in adverse action against the submitting agency and the clinician verifying the diagnosis.