Treatment MIS – Treatment Activity Form – FY 2007
Clinic ID: ____ Facility Code: ___ Program Type: __ Counselor
ID: ________
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ASAM
Level |
Client
ID |
Fund
Code |
Service
Beg. Date |
Service
End Date |
Activity
Code/ Tx Level |
Units of
Service |
Client
Fees |
3rd
Party Payments |
Medicaid
Payments |
Bill
Code |
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