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Jordan Ellis (C-0001) blocked

ARTS continued stay. Packet extension. Version 1.

This assembly cannot be signed as a completed continued-stay packet. It lists exactly what the coordinator must still supply.

Draft

DRAFT — synthetic continued-stay request (continued-stay form)

Client: C-0001   Level: 2.1

Existing authorization number and requested end date
Current end 2026-10-12. Authorization number not in the import.
(prefilled from the chart import; a person confirms)

Last three alcohol and drug screens
[NOT FILLED IN]

All medications prescribed by the SUD provider, with response
[NOT FILLED IN]

Dimension 1 to 6 ratings with summaries and attachments
Assessment dated 2026-09-23 covers dimensions 1, 2, 3, 4, 5, 6.
(prefilled from the chart import; a person confirms)

How the member is progressing under the current plan
[NOT FILLED IN]

Revised treatment goals
[NOT FILLED IN]

Full discharge plan
[NOT FILLED IN]

Projected discharge date
[NOT FILLED IN]

6 required fields still empty. This packet cannot be signed.

Library references: A-011, A-014, A-049. The A-011 timeframe is recommended and requires confirmation against this payer's profile.

Human review and signature required. Nothing is transmitted.

Gate blocked

  • evidence Last three alcohol and drug screens (continued-stay form) is not filled in.
  • evidence All medications prescribed by the SUD provider, with response (continued-stay form) is not filled in.
  • evidence How the member is progressing under the current plan (continued-stay form) is not filled in.
  • evidence Revised treatment goals (continued-stay form) is not filled in.
  • evidence Full discharge plan (continued-stay form) is not filled in.
  • evidence Projected discharge date (continued-stay form) is not filled in.

Fill in the packet 2/8

A person types these. The Agent never writes the clinical argument. Saving a field rebuilds the draft and voids any signature.

From the plan's approval letter and the requested new end date. Prefilled from the chart import; confirm or correct it.

Date, result and substances for each. Use the screen log, not memory.

Name, dose, and how the member responded.

One line per dimension, plus the attachments you will send. Prefilled from the chart import; confirm or correct it.

In the clinician's own words, tied to the plan's goals. Latest plan in the import: comprehensive, dated 2026-10-04.

What changes in the plan if the stay continues.

Discharge level of care, receiving agency, transition coordination done, and the MAT plan with scheduled appointments for OUD.

A date.

Sign

Required role: clinician. The other role is refused. The signature date is the chart date 2026-10-08. This form has no date field.

This records a signature on this computer. It does not file or send the packet.

Citations

Evidence

  • EV-EXT
  • EV-AUD

Audit trail

  • 11 draft-created · 2026-10-15T15:29:48.993Z · Extension checklist assembled; missing form, payer profile and attachments block sign-off.