Note that this form is not for claiming, a service note must be completed to claim.
Client Information
Client:
InSyst #	Last Name	First Name
Location:	Episode Opening Date:
Agency:	RU:
Services were provided in:	by ☐ interpreter or ☐ clinician
Instructions
For each beneficiary, Continuing Services Justification (CSJ) recommendation must be completed no sooner than 5 months and no later than 6 months after date of admission or date of last CSJ.
SUD Counselor or LPHA
Date of Most Recent IMN or CSJ:
Required Recommendation (choose one): ☐ I have reviewed this beneficiary's progress and eligibility to continue to receive treatment services and RECOMMEND client continue to receive treatment services. ☐ I have reviewed this beneficiary's progress and eligibility to continue to receive treatment services and DO NOT RECOMMEND client continue to receive treatment services.
Counselor/LPHA Comment (optional):
Signature of LPHA/SUD Counselor	Printed Name/Credentials	Date