OASAS believes prevention is a pro-active, research-based, data-driven process using proven-effective strategies and programs to reduce or prevent alcohol and other drug. ny. Select option: NYS Photo ID or Non NYS Photo ID NOTE: The information must match exactly. NYS Office of Addiction Services and Supports (NYS OASAS) 1450 Western Avenue, Albany, NY 12203Prevention Framework. sharing your account userid and password with someone else) will result in the temporary suspension of your account privileges until required remedial action is taken by executives at your facility. means a patient placement criteria system designed to assure that a client in need of substance use disorder services is placed in the least restrictive, but most clinically appropriate level of care available that is to be used in making all initial and ongoing level of care decisions in New York State. 00 CASAC: Renewal CPP: Section I & Renewal CPS: Section I & Renewal SW CE. 0 is a web-based instrument designed for NYS treatment providers and referral sources to guide decision making regarding the appropriate level of care for patients with substance use disorders. When you log into LOCADTR 3. The Monroe County Office of Mental Health oversees the Addiction system and provides funding to a number of community agencies for the provision of addiction services for individuals, families and the community. LOCADTR 3. CASAC-Trainee and CASAC-Provisional Extension Fee: $100. LOCADTR for Gambling Treatment is used by substance use treatment providers with a gambling designation to admit and treat for problem gambling only or as a co-occurring. Violation of the security and use agreement (e. The LOCADTR is a web-based tool developed to assist treatment providers, Medicaid Managed Care plans, and other referral sources, in determining appropriate levels of. please address questions or concerns to [email protected], pursuant to Executive Law Section 202-a, the language access law enacted by Governor Hochul in April 2022, each New York State agency that provides direct public services is required to provide translation of their vital documents in the twelve (12) most common non-English languages spoken by individuals in New York with LEP. The assessment ID will appear on the assessment table located on the LOCADTR dashboard only for the clinician who completed the assessment. LOCADTR 3. The New York State Office of Addiction Services and Supports (NYS OASAS) today announced the opening of the first Mobile Medication Unit (MMU) in New York State. NYS Office of Addiction Services and Supports (NYS OASAS) 1450 Western Avenue, Albany, NY 12203Первый выпуск! Комиссар Чиназо Каннингем присоединился к нашему первому выпуску, чтобы рассказать об OASAS, нашей миссии и будущем системы наркологической помощи в New York State. . Housing Providers help homeless or at-risk families with a history of substance use disorder obtain stable housing and employment, which promotes recovery. Open. , was appointed by Governor Kathy Hochul on December 1, 2021 and confirmed by the New York State Senate on January 24, 2022 as Commissioner of the New York State Office of Addiction Services and Supports (OASAS). We examined the predictive validity of the LOCADTR recommendation for. New York’s Medicaid State Plan includes authority for a. sharing your account userid and password with someone else) will result in the temporary suspension of your account privileges until required remedial action is taken by executives at your facility. source to identify the most appropriate treatment setting closest to the client's community. I hereby confirm that I have read and understood the User Security and Use Policy. Return to the Health Commerce System. g. Further information on LOCADTR 3. Dr. This new mobile unit is being operated by Bridging Access to Care, and is being supported with $225,000. Violation of the security and use agreement (e. 02. LOCADTR tests are managed by the OASAS Bureau of Addiction Treatment and Recovery (ATAR). All Inpatient SUD services require facilities to perform daily clinical review of the patient. Program Location. New York Medicaid covers all ambulatory LOCADTR LOCs, as well as medication-assisted treatment (MAT), residential and inpatient services and withdrawal management. NYS Office of Addiction Services and Supports (NYS OASAS) 1450 Western Avenue, Albany, NY 12203LOCADTR tests are managed by the OASAS Bureau of Addiction Treatment and Recovery (ATAR). This interactive dashboard includes data on drug overdose deaths in New York State by year, substance type, county, and race/ethnicity. 820. Clinical Support Trainings. g. please address questions or concerns to [email protected] Addiction Resource Centers are regional hubs that connect NYers to appropriate services and work to increase community education and raise awareness about addiction. HSE – High School Equivalency 4. ny. Office of Addiction Services and Supports. It can be found on the Assessment Dashboard page of LOCADTR 3. 0 web-based tool and is the first column next to Client name. The division also provides clinical and reimbursement guidance to providers to ensure addiction services are delivered in compliance with the recently issued Clinical Standards for Certified Providers, which details clinical treatment expectations across all. g. Open. Important Site Notices. 0 Protocol has been mandated for all OASAS certified substance use disorder treatment providers to be utilized to determine the most appropriate level of. In New York State, screening related to substance use must be related to professional scope of practice. NYS Office of Addiction Services and Supports (NYS OASAS) 1450 Western Avenue, Albany, NY 1220306/12/2019. Open. ny. Office of Addiction Services and Supports. 0, a web-based tool, to assist substance abuse treatment providers, Medicaid Managed Care plans, and other referral sources in determining the most. 1016/j. g. 0” or “level of care determination protocol. Based on the LOCADTR 3. NYS OASAS is requiring all NYS Medicaid managed care, all private insurance companies and all. Albany, NY 12231-0001, and may be viewed at the law libraries of the New York State Supreme Court, the Legislative Library in the NYS Capitol, or viewed by appointment with the New York State Office of Addiction Services and Supports, Office of Counsel, 1450 Western Ave. Cunningham is a physician, researcher, and public health professional who brings. m. 40, 32. gov. ny. Follow the instructions provided on the form to enter your address, phone number, and email. Violation of the security and use agreement (e. Albany, NY 12231-0001, and may be viewed at the law libraries of the New York State Supreme Court, the Legislative Library in the NYS Capitol, or viewed by appointment with the New York State Office of Addiction Services and Supports, Office of Counsel, 1450 Western Ave. 0, a new tool to help Medicaid Managed Care plans and Health Homes manage access to. Established users do not need to access different modules. “LOCADTR 3. The facility may fax or email the OASAS Appendix A Notification Form and OASAS LOCADTR Medical Necessity Tool to 646-829-1421 or [email protected] Created Date:The Impaired Driver System is a web-based tracking and reporting application developed by the Office of Addiction Services and Supports in collaboration with the New York State Department of Motor Vehicles. C. NYS Office of Addiction Services and . . Treatment Planning Treatment planning begins at the first conversation with an individual about their gambling concerns. Office of Addiction Services and Supports. It includes information. 1. Open. NYS has long funded the majority of addictions treatment. The following approved screening tools include tools developed for the general population as well as tools that have been developed and validated for specific populations: adolescents, older adults, and pregnant persons. Level of Care Determination (LOCADTR) Office of. Access LOCADTR via the Health Commerce System (HCS) - 3 Step Process Step 1 Affiliate your Clinic with the HCS Send an email to [email protected]. Open it up with online editor and start adjusting. NYS OASAS, in partnership with National Center on Addiction and Substance Abuse at Columbia University (CASAColumbia), dev the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3. NYS Education Law Section § 6902 defines the practice of nursing as follows: Definition of practice of nursing. ) D. Reset Password. NYS Office of Addiction Services and Supports (NYS OASAS) 1450 Western Avenue, Albany, NY 12203and the New York State Office of Alcoholism and Substance Abuse Services (OASAS); and OASAS to . . . org. Related Content - locadtr pdf Level of Care Determination (LOCADTR) | Office of Addiction. The facility may fax or email the OASAS Appendix A Notification Form and OASAS LOCADTR Medical Necessity Tool to 646-829-1421 or [email protected] LOCADTR. ny. Office (585) 461-0410. 0, a web-based tool, to assist substance abuse treatment providers,. Learn about the Level Of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3. ny. AMENDED PART 818 EFFECTIVE OCTOBER 1, 2022 . 8 . . County. . Open. Background: The New York State (NYS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) was launched in 2015 to determine the most appropriate. , Albany,. The setting in which the service is. 09(b), 19. sharing your account userid and password with someone else) will result in the temporary suspension of your account privileges until required remedial action is taken by executives at your facility. The LOCADTR admission tool relies on a clinical assessment addressing the factors. sharing your account userid and password with someone else) will result in the temporary suspension of your account privileges until required remedial action is taken by executives at your facility. please address questions or concerns to LOCADTR@oasas. new york state office of alcoholism and substance abuse services consent to release of information concerning alcoholism/drug abuse patient locadtr assessment instructions: give a copy of this form to patient! prepare one (1) copy for the patient's case record. • Provide oversight and evaluate effectiveness of the utilization management and care management programs of our delegated partners. LOCADTR- G Level of Care for Alcohol and Drug Treatment Referral for Gambling Treatment 3. They. Providers of Clinical Screening and Assessment Services for the Impaired Driving Offender. Open. ny. Outpatient Services are for those who do not require 24/7 supervision or support while addressing their addiction. Screening, Brief Intervention and Referral to Treatment (SBIRT) is an evidence-based approach to identify individuals who use alcohol and other drugs (substances) at risky levels. Fentanyl and xylazine test strips ship in a 100-pack. 0, originally developed for SUD treatment providers and managed care organization. 02% or more but less than . Resources. sharing your account userid and password with someone else) will result in the temporary suspension of your account privileges until required remedial action is taken by executives at your facility. Working together with our partners at OASAS, Emergent and NY Matters we will help avoid needless tragedies. g. Providers & Workforce | Office of Addiction Services and Supports. gov. Unit . Since 2015, the LOCADTR has been the required LOC determination tool for the more than 900 state-certified treatment programs in NYS, as well as MCOs, for clients who are covered by Medicaid managed care. The LOCADTR is a required tool for determining the most appropriate level of care for individuals seeking treatment. . Find the NY LOCADTR 3. (a) New York State criteria for level of care. gov. Screening quickly assesses the severity of substance use and identifies the appropriate level of treatment. Providers may obtain this form by contacting the Driver Improvement Unit at: Driver Improvement Unit. If a person uses the “Other Clinicians’ option to retrieve Violation of the security and use agreement (e. gov. The agency has a clear policy and procedures for assignment of cases and monitoring of caseload size to ensure that all clients can expect quality treatment. Data is a valuable tool in understanding the scope of the drug overdose crisis in our state and allows us to better target interventions to those who are most at risk and prevent needless deaths. 12(b)(1-2). please address questions or concerns to LOCADTR@oasas. 0 is completed,. Based on the New York State Office of Alcoholism and Substance Abuse Services (OASAS) 2010 estimates, approximately twelve percent of State residents age 12 and older experience a substance use disorder (addiction or abuse) annually. Blaisdell provides addiction treatment services for male registered sex offenders. The NYS LOCADTR is the focus of the current study. TOP. NYS OASAS WEB APPLICATIONS. First Name Must match your Photo ID. Violation of the security and use agreement (e. Violation of the security and use agreement (e. gov. please address questions or concerns to [email protected] for educators and administrators, school nurses counselors and other school staff can address drug, alcohol, gambling and e-cig use in school settings. ” OASAS oversees one of the nation's largest substance use disorder systems of care with approximately 1,700 prevention, treatment, harm reduction and recovery programs serving over 731,000 individuals per year. NYS Office of Addiction Services and Supports (NYS OASAS) 1450 Western Avenue, Albany, NY 12203LOCADTR tests are managed by the OASAS Bureau of Addiction Treatment and Recovery (ATAR). Avoid using alone, and if you do, call the Never Use Alone Hotline at (800) 484-3731 to have an operator stand by while you use. gov. Created Date: 6/29/2018 2:50:52 PM Health Commerce System. NYSERDA Portal Customer Secure Login Page. You can only do so with the OASAS application url provided here. Address. Problem Gambling Treatment and Prevention. Define LOCADTR. g. Date Of Birth (YYYYMMDD) Gender (M/F/X) Gender M F X. Background. . sharing your account userid and password with someone else) will result in the temporary suspension of your account privileges until required remedial action is taken by executives at your facility. “LOCADTR 3. 12 Level of care criteria. LOCADTR’s are appropriate only for those with a Substance Use Disorder Diagnosis. Launch LOCADTR 3. The goal of the campaign is to explain the work that these providers do and. Self-Help . (NYS OASAS) 1450 Western Avenue, Albany, NY 12203Violation of the security and use agreement (e. Clinical Support Trainings. 5 . Register for an Account. NYS OASAS, working in collaboration with the NYS Department of Health, is using the Health Commerce System (HCS) to access and support LOCADTR tools. If a person uses the “Other Clinicians’ option to retrieve this information they/them will have to downloadSpecialty services for specific populations including youth and young adults, pregnant persons, criminal justice-involved individuals, and the LGBTQ+ community are available and expanding statewide to better meet the needs of all New Yorkers. g. Company Search. For help and hope 24/7, call 1-877-8-HOPENY(467369) or text HOPENY (467369). Open. 0 and clicking on the gambling module. Sign out OASAS Account Logged /n setect from the coticns Learning Open OASAS Special Webinar OASAS LOCADTR Loc *DTP of cps supports Sign In Go The 10 ASAP S Board ASAP-NYCa 2012-2022 . have read the above and authorize the New York State Office of Alcoholism and Substance Abuse Services and the staff of the OASAS-certified treatment facility named above to disclose and obtain such information as herein specified. Please direct all questions to picm. . If you are traveling or exploring NYC,. . please address questions or concerns to [email protected]. sharing your account userid and password with someone else) will result in the temporary suspension of your account privileges until required remedial action is taken by executives at your facility. . 00 CASAC: Renewal CPP: Section I & Renewal CPS: Section I & Renewal SW CE. PG – Problem Gambling 6. Each element has its own admission criteria; reintegration has additional criteria found in Section 820. . sharing your account userid and password with someone else) will result in the temporary suspension of your account privileges until required remedial action is taken by executives at your facility. To become a CASAC in New York State, you must: (1) meet specific competency and ethical conduct requirements; (2) meet specific work experience requirements; (3) meet minimum education and training requirements; (4) successfully. Further information on LOCADTR 3. Violation of the security and use agreement (e. Program / Plan Use of. PG – Problem Gambling 6. The use of LOCADTR 3. please address questions or concerns to LOCADTR@oasas. OASAS works closely with Criminal Justice partners to help offenders access treatment. Medical/Clinical necessity is the verification and documentation to support that the services the If you do not have a NYS driver license or NYS non-driver photo ID or you did not set up your security questions/answers, you must call the Commerce Accounts Management Unit (CAMU) at 866-529-1890 option 1 to have your password reset. please address questions or concerns to [email protected], a web-based tool, to assist substance abuse treatment providers, Medicaid Managed Nursing plans, and other referral sources stylish determining the. You can also find your username in the welcome email sent to you from NYSERDA. gov. 5c “Admission assessment” is a. ny. These efforts include: OASAS monitors substance use disorder programming in 52 NYS Department of Corrections and Community Supervision facilities. . 2 2019 TABLE OF CONTENTSEnter all the fields below, check the I'm not a robot checkbox, and click the Email me the User ID button. trs-62 (8/16) ¨ ° ¯ ¨ ¬ ¤ ° וּ ² ° © £ ¡ © ¶ · © £ וּפֿ ©פֿ וּפֿ ©פֿ ² © ¶ ® ¸ פֿ ° ² פֿ ¡ וּ °וּ © ¨ ¹וּFor help with OASAS Applications: OASAS staff call (844) 891-1786; other users call (518) 485-2379, fax (518) 473-1316, or email [email protected] you or someone you know uses substances, they are at risk of experiencing an overdose. Help & Hope Text Program: Text JOIN to 55753 to receive personalized support messages or connect with a specialist. Download. NYS has long funded the majority of addictions treatment. Introduction On August 2, 2021, the . be effective prior to or on the date of the implementation of Medicaid Managed Care in New York City (October 1, 2015). For help with OASAS Applications: OASAS staff call (844) 891-1786; other users call (518) 485-2379, fax (518) 473-1316, or email healthhelp@its. ny. OASAS monitors all certified or funded addiction treatment providers across the state to ensure strict compliance with agency regulations and state and federal laws. JAD : Joint Application Development . Violation of the security and use agreement (e. “LOCADTR 3. The manual explains the purpose, features, and functions of the LOCADTR 3. E M E D N Y IN F O R M A TI O N . Open. NYS Office of Addiction Services and Supports (NYS OASAS) 1450 Western Avenue, Albany, NY 12203LOCADTR tests are managed by the OASAS Bureau of Addiction Treatment and Recovery (ATAR). Modern Contemporary California Connecticut New York City White Spaces Event Space Farm New Jersey Long Island Apartment School Theatre Stage. Rochester, NY 14620. Open. You can usually do this by double-clicking on the file or right-clicking and selecting "Open with" and then choosing a PDF reader program. The New York State (NYS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) was launched in 2015 to determine the most appropriate level of care for individuals seeking addiction treatment. The New York State Office of Addiction Services and Supports (OASAS) oversees one of the nation’s largest Substance Use Disorder systems of care with approximately 1,700 prevention, treatment and. govScreening and Referrals. 08%. COVID Regulatory. Enter your HCS User ID, fill in the rest of the fields matching the information from your NYS driver license or non-driver photo ID, and click the Reset Password. Clinical Support Trainings. ItRequest for Applications #SUPP1019. NYS Office of Addiction Services and Supports (NYS OASAS) 1450 Western Avenue, Albany, NY 12203I consent to the disclosure of confidential information to, and among, the New York State Office of Addiction Services and Supports (OASAS), th e CASAS-Certified treatment facility identified above, and New York University School of Medicine of my clinical treatment including information from the Treatment Progress Assessment (TPA8) database. 108559 . It covers topics such as admission criteria, treatment planning, medication services, discharge planning, and quality assurance. , was appointed by Governor Kathy Hochul on December 1, 2021 and confirmed by the New York State Senate on January 24, 2022 as Commissioner of the New York State Office of Addiction Services and Supports (OASAS). . Examination Retest Fee: $245. NYS Office of Addiction Services and Supports (NYS OASAS) 1450 Western Avenue, Albany, NY 12203143 White Birch Road Indian Lake, NY 12842. ny. 0 Assessment (if no LOCADTR 3. sharing your account userid and password with someone else) will result in the temporary suspension of your account privileges until required remedial action is taken by executives at your facility. 1-4: How is the OASAS Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3. This courses facilitates the use of the LOCADTR and helps clinicians to distinguish between the LOCADTR and the LOCADTR Continuing Review Module. Use one of the following criteria to generate a list of desired companies:LOCADTR tests are managed by the OASAS Bureau of Addiction Treatment and Recovery (ATAR). ny. Over $190 million in opioid settlement monies have been made available to date. LOCADTR : OASAS Level of Care for Alcohol and Drug Treatment Referral system . Addiction Services Overview. The url is: You cannot access LOCADTR from the HCS home page. g. Referral (LOCADTR). Do you complete a toxicology screen for a significant other in the course of the assessment? Toxicology testing supports treatment for substance use disorder. 24/7 Open Access Centers and Centers of Treatment Innovation increase access to assessments, referrals, and familial support. The target webpage is a PDF document that contains the OASAS regulations for operating chemical dependence outpatient and opioid treatment programs in New York State. gov. sharing your account userid and password with someone else) will result in the temporary suspension of your account privileges until required remedial action is taken by executives at your facility. sharing your account userid and password with someone else) will result in the temporary suspension of your account privileges until required remedial action is taken by executives at your facility. The New York State Office of Addiction Services and Supports (NYS OASAS) today announced the opening of the new Gregory E. User ID. The following is a series of lists sorted alphabetically of current cities, towns, unincorporated communities, counties, and other recognized places in the U. sharing your account userid and password with someone else) will result in the temporary suspension of your account privileges until required remedial action is taken by executives at your facility. Addiction services may not be provided in inpatient or outpatient hospital settings. First, gather all the necessary information such as personal details, contact information, and any relevant documents. sharing your account userid and password with someone else) will result in the temporary suspension of your account privileges until required remedial action is taken by executives at your facility. 0” or “level of care determination protocol. If our LOCADTR results match with your provider’s results, your continued care is approved. In study 1, 139 providers used the LOCADTR 3. 0 can be found here-The NYS LOCADTR is the focus of the current study. Don't Have An Account? Violation of the security and use agreement (e. Universal OASAS Residential Application, June 2009, Page 4 Catholic Family Center Stabilization Freedom House (male) (585) 546-7220 ext. New York State Substance Use Disorder treatment providers and managed care plans have utilized the LOCADTR admission tool for determining recommended level of care since October of 2015 when all SUD services were integrated into Medicaid managed care. g. Clinical Support Trainings. Login to your NYSERDA Portal Customer Account. 0 Assessment (if no LOCADTR 3. Last Name. Specialties include:Office of Addiction Services and Supports. ny. The use of LOCADTR 3. ny. Open. If a person uses the “Other Clinicians’ option to retrieve this information they/them will have to download Specialty services for specific populations including youth and young adults, pregnant persons, criminal justice-involved individuals, and the LGBTQ+ community are available and expanding statewide to better meet the needs of all New Yorkers. my. Toll-free and confidential. SAMHSA guidance and resources to assist individuals, providers, communities, and states dealing with the COVID-19 emergency. LOCADTR is developed and. *New York State Office of Addiction Services and Supports, State of New York, Chapter 57 Inpatient Substance Use Disorder and Mental Health Treatments For members of AmeriHealth Administrators GeoBlue plan only Effective Jan. sharing your account userid and password with someone else) will result in the temporary suspension of your account privileges until required remedial action is taken by executives at your facility. 2021. Download. HSE – High School Equivalency 4. of research and program evaluation activities. means a patient placement criteria system designed to assure that a client in need of substance use disorder services is placed in the least restrictive, but most clinically appropriate level of care available that is to be used in making all initial and ongoing level of care decisions in New York State. gov. D. Clinical Support Trainings. $8,000. 0 and clicking on the gambling module. NYS DOH - Development of a Comprehensive Coroner Training Program: $400: In process: 8/29/23. gov. LOCADTR for Gambling Treatment is used by substance use treatment providers with a gambling designation to admit and treat for problem gambling only or as a co-occurring disorder. School physicians and counselors can incorporate screening questions into regular check-ins with students to help identify risk factors early and prevent addiction later in life. Previous research on the LOCADTR indicated that it has acceptable interrater reliability and content-related validity. xviii. gov. Learn more about Consent to Disclose Communicable Diseases TRS-7 Client LOCADTR Assessment (TRS-62) applies to LOCADTR data entry. please address questions or concerns to LOCADTR@oasas. EHR for State-Operated AddictionViolation of the security and use agreement (e. 1. o When a crisis assessment and/or LOCADTR indicates that a recipient requires a higher level of care, Centers will make every attempt to engage the recipient until a direct connection to the appropriate service provider is complete. TREATMENT/SERVICE PLANNING ____ ____The New York State Office of Addiction Services and Supports (NYS OASAS) today announced the launch of the “Stick to the Game Plan” campaign. How much can I request? Naloxone has a shelf life so we ship two doses per order and offer both intranasal and intramuscular naloxone. We'll discuss all things prevention, harm reduction, treatment, and recovery, and highlight the importance of specialized services. 0 Concurre. New York State Office of Information Technology Services . Program leadership can demonstrate a systematic process used to. OASAS oversees and establishes guidelines for the comprehensive statewide education and training of New York's credentialed addiction professional workforce and all staff who provide treatment, prevention. You can measure by feet, meters, yards, kilometers, miles or. Open. All fees must be made in the form of a check or money order and made payable to “NYS OASAS”. The opioid crisis has spurred communities to. Clinical Support Trainings. 0 you may choose the Gambling LOCADTR module or the concurrent review LOCADTR. ny. Opioid Settlement Fund Advisory Board. NEW YORK STATE OFFICE OF ADDICTION SERVICES AND SUPPORTS REQUEST FOR APPLICATIONS (RFA) SUPP1008 Comprehensive Integrated Outpatient Treatment Programs EXPECTED TIMETABLE FOR KEY EVENTS: DATE TIME RFA Release Date 3/25/2022 5:00 PM EST Deadline for Submission of Applicant’s Inquiries 4/1/2022 5:00. You need prior approval for mental health. NYS Office of Addiction Services and Supports (NYS OASAS) 1450 Western Avenue, Albany, NY 12203NYS OASAS, in partnership with National Media on Habituation and Essence Abuse at Kolumbia University (CASAColumbia), designed the Level regarding Service for Alcohol press Medical Treatment Referral (LOCADTR) 3. please address questions or concerns to [email protected]. NEW YORK STATE OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES CONSENT TO RELEASE OF INFORMATION CONCERNING ALCOHOLISM/DRUG ABUSE PATIENT LOCADTR ASSESSMENT Revoked On: _____ Staff Initials: _____ Patient's Last Name First M.