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0371T with multiple family group name and ID are needed to ensure that both pages are for same individual Concurrent TREATMENT REPORT ABA Provider Report Guidelines are available on ValueOptions. Behavioral Y N NA Medical Community Services Regional/State Program Educational Program Current Medications including Psychotropic Dosage and Frequency Treating Provider s Signature Date Completed form can be faxed to 855-241-8895 or mailed to Horizon BCBSNJ Horizon Behavioral Health PO Box 4274...

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