OCHN SRS/CLS Discharge Reporting Form

SUBMIT TO OCHN BY THE 10TH OF MONTH FOLLOWING THE REPORT PERIOD To the Provider Network Team at ‘ottmand@oaklandchn.org’ and ‘yorka@oaklandchn.org’

Section 2

Individual Served Information

Include list of providers that have declined, date declined, and reason for declining

i.e Supervisor, Managers, etc

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