DELAWARE HEALTH 
AND SOCIAL SERVICES 
Division of Substance Abuse and Mental Health 
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 
Mediciad Yes No 
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 Licensed MH Group Home 
Recertification Effective Date: / / End Date: / / 
Physician Signature: Date: / / 
Part III 
CMHC/DPC Review of Certification (completed by CMHC) 
(Due 15 days after recertification) 
The physician’s certification and the Delaware Reassessment Packet have been reviewed by the Community 
Mental Health Center and found to be complete. 
Agency Authorized Representative Signature: Date: / / 
Authorized Units: Authorized Months/Days: 
DSAMH Revised 12/02 CSP-RECERT.DOC