FSP RESIDENTIAL PLACEMENT FORMS

To facilitate and verify a FSP youth’s admission into a residential treatment facility, the SASS Provider must fax the appropriate FSP residential placement form(s) to eQHealth Solutions:

An Initial Request for Residential Treatment

Once SASS receives prior approval and confirms RTF placement within the approved 90 days, the FSP Coordinator will complete and fax the FSP Residential Placement Form to eQHealth within 3 business days after the youth’s admission

CLICK HERE for a copy of the FSP Residential Placement Form
Please fax the completed  form to (800) 418-4039 with a Subj: FSP RTF Placement.

 

A Residential Treatment Facility Transfer

Whenever a residential treatment facility has determined that a youth in its care requires a transfer to  another HFS-registered residential treatment facility, the RTF must contact the youth’s FSP Coordinator and provide information why a transfer has been initiated. The SASS/FSP Coordinator will complete and fax the
FSP Residential Transfer Form to eQHealth Solutions within 3 business days after the youth’s admission into the new facility
.

CLICK HERE for a copy of the FSP Residential Transfer Form
Please fax the completed form to (800) 418-4039 with a Subj: FSP RTF Transfer. 

IMPORTANT NOTE! These forms are required to notify eQHealth/HFS of residential placement of the FSP youth. Once received, eQHealth Solutions will send a letter to the appropriate Residential Treatment Facility authorizing an initial 60 days of residential care. The letter will contain the approved dates of service, separated into two, 30-day stays for billing purposes.