SUD Demographics Form

A demographics form is required by NMRE for all clients who enter Substance Use Disorder Treatment for each level of care.                    
The demographics form should be submitted to the RECON fax queue at intake. NMRE processes the demographics form and 
creates the referral upon receipt.  Forms are processed in the order received and can take up to 24 hours for processing.

The form has been updated to include the new initial authorization options for Outpatient services.  

Please choose one of each of the following:  
Assessment - H0001 or No H0001 Needed.  
Treatment Planning:  H0004 - 4 units (BL) or 9083X - 1 unit (ML).

Before submitting the Demographics form, please check that all required information has been completed and is accurate. 

Incomplete demographics forms are returned through a RECON system message, to the RECON contact person(s). Messages are sent through to provider staff as demographics are returned. 

While it is required that there is a Consent Form (MDHHS - 5515) it is no longer required to accompany the demographic form or have the NMRE listed on the form. 

If you do not see a referral in the RECON system after 24 hours and the demographics form has not been returned to your RECON contact, please send a message to providersupport@nmre.org.
Creation date: 11/8/2017 2:18 PM ()      Updated: 1/7/2019 1:14 PM (vmcbain@nmre.org)
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Demographic Sheet 12.21.18 Update.docx
Demographic Sheet Fillable 20190107.pdf