DELAWARE HEALTH AND SOCIAL SERVICES Division of Substance Abuse and Mental Health ALCOHOL AND DRUG COMMUNITY SUPPORT PROGRAM Recertification Form . Part I Completed by CSP Program Consumer Name: Last First M.I. Consumer MCI# D.O.B. / / (10 digits) mm dd year Part II Physician Recertification (Completed by CSP Physician) (Due 15 days before current certification period terminates) CSP Program Name: Admission Date: / / Date Current Certification Terminates / / Certification Due Date / / (15 days before termination) Based on the indications of the Delaware Assessment Packet completed on / / and my examination of / / documented in the client record, I hereby certify that the provision of the following community support rehabilitation services , medically necessary for the above named consumer. (are) (are not) CTT Level I CTT Level II Other Recertification Effective Date: / / End Date: / / ( 1year maximum) Physician Signature: Date: / / Part III SET/DSAMH Review of Certification (completed by SET/DSAMH ) (Due 15 days after recertification) The physician’s certification and the Delaware Reassessment Packet have been reviewed by the Screening and Evaluation Team/DSAMH and found to be complete. Agency Authorized Representative Signature: Date: / / DSAMH Revised 12/02 CSP-AD-RECERT.DOC