Client Name:
(updated 2/19/13)
Male Female DOB/Age:
Date(s) of Service: Time(s) of Service: MID #
Clinician’s Name/Credentials:
IDENTIFYING INFORMATION AND REASON FOR REFERRAL:
HISTORY OF PRESENT ILLNESS (DESCRIPTION OF PRESENTING SITUATION): (Why is participant seeking services
now?)
Yes No Client has experienced and/or is currently experiencing life / traumatic experiences that are contributing to current symptoms / inability to function effectively. See attached Comprehensive DX Assessment Client Questionnaire completed by the client / parent.
Yes No Client is currently experiencing symptoms of mental illness / de-compensation warranting treatment. See
Evaluator’s Summary of Current Symptoms on page six of this CDA. (Must be “Yes” to continue assessment. If the answer is “No”, discontinue CDA.
PARTICIPANTS OVERALL GOAL FOR SEEKING SERVICES (INCLUDE CLIENT QUOTE): (How will you know that you are done with treatment? What will be different in your life?)
PSYCHIATRIC HISTORY (including hospitalizations, suicide attempts, trauma/abuse, previous medications, substance use and other inpatient or outpatient services:
1

SUBSTANCE USE HISTORY (assess experimental/recreational/dependency/abuse): Denies Substance Use
Alcohol: Opiates:
Marijuana: Prescription Drugs:
Meth/crank/speed: Hallucinogens:
Tobacco:
Other:
Elaboration:
Caffeine:
1.
List client’s top three current skills for coping with symptoms of diagnosis.
1.
2.
3.
2.
Check the strengths that apply to this client:
Client has insight into his / her illness
Client has not been hospitalized during the past year for psychiatric reasons
Client maintains medication compliance
Client can identify symptoms
Other: ___________________________________________________________________________________
FAMILY PSYCHIATRIC HISTORY (diagnosis, hospitalizations, substance abuse etc):
MEDICAL HISTORY:
Major medical problems include:
Asthma Diabetes
Cardiovascular problems Musculoskeletal problems
Surgeries
Other:_______________
Overnight Hospitalizations
Current primary care physician
Please elaborate on above:
Seizures
Endocrinologic problems
Head Injuries
Serious Injuries
History diabetes cardiac/stroke
2

HEALTH OR MEDICAL ISSUES (addresses participant’s skills for self-managing health and medical issues)
1.
Yes No Client’s symptoms negatively impact participant’s ability to schedule and keep appointments as well as his / her ability to communicate with providers.
2.
Yes No Client’s current ability to consistently and appropriately adhere to medical regime is negatively impacted by symptoms.
3.
Check the strengths that apply to this client:
Client maintains medication compliance
Client is able to communicate needs to his / her physician
CURRENT MEDICATIONS: See attached Comprehensive DX Assessment Client Questionnaire completed by the client / parent.
Client follows through with medical appointments
Other: _________________________________________________________________________________
ALLERGIES:
CLIENT GOALS for Health/Medical:
SOCIAL HISTORY
( Housing, family status, losses, grief, trauma, supports/strengths/skills):
Marital Status: S M D W # of marriages: _______ (ended by death or divorce)
Children: _______ Pregnancies/miscarriages/losses/adoption/terminations
1.
What is the client’s current housing situation?
Homeless House Group Home Apartment Other: ________________________________
Lives alone Lives with: _______________________________________________________________
2.
Yes No Client is negatively impacted by symptoms in his / her ability to obtain and/or maintain safe and appropriate housing.
3.
Check the strengths that apply to this client:
Client is able to access housing resources
Client is able to maintain housing
Client has supportive housing at the present time
Other: _________________________________________________________________
CLIENT GOALS for Housing:
3

SOCIAL RELATIONSHIPS AND SUPPORTS
1.
Yes No Client’s symptoms negatively impact his / her ability to establish and/or maintain support
systems, relationships, leisure activities, and recreational activities.
2. Check the strengths that apply to this client:
Client is able to maintain healthy relationships
Client is involved in one or more social / leisure activities
Client is able to socialize effectively with others
Other: _________________________________________________________________________________
CLIENT GOALS for Social:
Family
Yes No Client’s symptoms negatively impact his / her ability to carrying out family roles and/or participating in family relationships. If yes, explain:
Check the strengths that apply to this client:
Client understands his / her role in his /her family
Client has supportive family outside his /her residence
Client has a health relationship with family members
Other: __________________________________________________________________________________
CLIENT GOALS for Family:
CHILDHOOD HISTORY
DEVELOPMENTAL HISTORY Within Normal Limits Unknown Other
Family of Origin: (adoptions/out of home placements/unplanned pregnancies/environment)
BASIC LIVING SKILLS / INDEPENDENT LIVING SKILLS
1.
Yes No Client’s symptoms negatively impact and limit the client’s abilities to perform age appropriate basic living skills, including his / her ability to adhere to daily schedule. (For children this includes transition into adulthood)
2.
Client’s current problem solving abilities are very good adequate poor very limited
4

3.
Check the strengths that apply to this client:
Client is able to follow a daily routine
Client is able to maintain hygiene needs
Client is able to execute some basic tasks
Other: ________________________________________________________________________________
CLIENT GOALS for Basic Living Skills:
VOCATIONAL AND EDUCATIONAL STATUS
1.
Yes No Client has involvement(s) with vocational rehabilitation, IEP, Special Education or other community programs. If yes, list which programs:
2.
What is the highest grade level achieved by the participant? _________________________________
3.
Yes No Client has experienced loss of skills or has not acquired skills appropriate for their developmental stage, which has negatively impacted functioning in work and/or school settings. If yes, list what client cannot do:
Check the strengths that apply to this client:
Client is able to maintain employment
Client is able to access Voc/Ed resources
Client is able to function in school appropriately
Client has support from school/teachers
Client has a school IEP, or other special assistance: _________________________________________
Other: ______________________________________________________________________________
CLIENT GOALS for Vocational/Educational:
FINANCIAL STATUS
1.
Client’s current income monthly is: ______________. His /her expenses monthly are: __________________
Client’s income resources come from: __________________________________________________________
2.
Yes No Client’s symptoms are negatively impacting the participant’s skills for managing personal finances
(relative to stability of accounts, debt incurred, spending habits).
3.
Yes No Does the client have a current payee? If yes, who: __________________________________
4.
Check the strengths that apply to this client:
Client is able to budget income
Client is able to differentiate between necessary spending and impulse spending
Other: _________________________________________________________________________________
CLIENT GOALS for Financial:
COMMUNITY AND LEGAL STATUS
1.
Yes No Client is currently involved in legal action(s). If yes, elaborate:
5

2.
Yes No Client’s symptoms relate to legal issues. If yes, check all that apply:
Symptoms directly caused legal action
Symptoms are exacerbated by legal issues/pressures
Other: ________________________________________________________________________________
3.
List any current community supports the client is involved with.
4.
Yes No Client’s symptoms have negatively impacted his / her skills necessary for community living (such as compliance with rules, laws, and informal agreements made with others).
5.
Check the strengths that apply to this client:
Client has avoided legal trouble over the last service year
Client has complied with probation terms over the last service year
Client is able to access community resources
Other: _________________________________________________________________________
CLIENT GOALS for Community/Legal:
MENTAL STATUS EXAMINATION:
Appearance:
Attitude:
Eye Contact:
Alert:
Adequately Groomed
Stated Age Younger Older
Cooperative
Oppositional
Unremarkable
Yes No
Pleasant
Hostile
Hostile/challenging
Mildly Sedated
Poor Hygiene
Thin
Frustrated
Indifferent
Withdrawn
Moderately Sedated
Disheveled
Overweight
Guarded
Other:
Withdrawn
Psychomotor: Calm
Mildly Increased
Involuntary Movement/Tics: No
Speech: Unremarkable
Attention/Concentration:
Mood:
Affect:
Thought Process:
Thought Content:
Anxious
Unimpaired
Unimproved
Euthymic
Angry
Hypomanic
Congruent
Sad
Mildly Decreased
Hyperactive
Yes
Delayed
Retardation
Impulsive
Anxiety
Agitated
Articulation Deficits
Impaired
Improved
Unchanged
Blunted
Rational
Anxious
Circumstantial
Concrete
Denied Suicide Ideation
Racing
Denied Homicidal Ideation
Loud
Increased Rate
Impaired by Anxiety
Worsened
Irritable
Soft
Pressured
Mild/Moderately Depressed
Manic
Incongruent
Full
Mixed Dysphoric
Labile
Expansive
Flat
Tangential
Anxious
Very Depressed
Tearful
Inappropriate
Constricted
Other:
Illogical
Flight of Ideas
+ Suicidal (Passive/Active)
Other:
+ Homicidal Ideation
6

Symptoms Present: No Paranoia
No Delusions
No OCD
No Hallucinations
+ Paranoia
+ Delusional
+ OCD Symptoms
+ Hallucinations (Auditory/Visual/Tactile)
Yes Self Destructive/Destructive Behavior:
Orientation/Memory:
Estimate of Intelligence
Intact
Average
Assessment Status: Stable
Slightly Improved
Essentially Unchanged:
No
Impaired
Above Average
Depressed but Stable
Markedly Improved
Favorable Unfavorable
Below Average
Anxious but Stable
Mildly Worsened
Unstable / Higher Level of Care / Hospitalize
Diagnosis: No Change Changed First assessment
Elaboration on client’s mental status and/or behavior:
SEVERITY of SYMPTOMS Note specifics, as needed.
1
Mildly disruptive
(Get over it easily)
2
Moderately disruptive
(Can manage it most of the time)
3
Significant disruption
(Can only manage it
50-60% of the time)
4
Very disruptive
(Can’t manage it
75-80% of the time)
Markedly Worsened
5
Severely disruptive
(Overwhelming, cannot function)
SYMPTOM LIST SEVERITY
ADULT PRIMARY PSR DIAGNOSES
295.30 Schizophrenia, Paranoid Type
295.70 Schizoaffective Disorder
296.33 Major Depression, Recurrent, Severe w/o Psychotic Features
296.5__ Bipolar I Disorder, Depressed
296.6__ Bipolar I Disorder, Mixed
296.89 Bipolar II Disorder
296.34 Major Depression, Recurrent, Severe with Psychotic Features
296.4__ Bipolar I Disorder, Manic
Modifiers for Mood Disorders
.04 Severe with Psychotic Features .00 Unspecified
.01 Mild
.02 Moderate
.03 Severe without Psychotic Features
.05 Partial Remission
.06 Full Remission
AXIS I – PSYCHIATRIC DISORDERS
295.4__ Schizophreniform Disorder
296.2__ Major Depression, Single
296.23 Major Depression, Single, Severe, w/o Psychotic
Features
296.24 Major Depression, Single, Severe, with Psychotic
Features
307.10 Anorexia Nervosa
307.51 Bulemia Nervosa
307.23 Tourette’s Disorder
309.0 Adjustment Disorder with Depression
309.21 Separation Anxiety Disorder
309.24 Adjustment Disorder with Anxiety
S
S
S
S
S
7

296.31 Major Depressive Disorder, Recurrent, Mild
296.32 Major Depressive Disorder, Recurrent Mod.
296.35 Major Depressive Disorder, Part Remission
296.36 Major Depressive Disorder, Full Remission
296.80 Bipolar Disorder, NOS
296.90 Mood Disorder, NOS
298.9__ Psychosis, NOS
299.00 Autistic Disorder
309.28 Adjustment Disorder with Depressive Mood & Anxiety
309.3 Adjustment Disorder with Disturbance of Conduct
309.4 Adjustment Disorder with Mixed Disturbance of Conduct and Emotions
309.81 PTSD
312.81 Conduct Disorder, Child Onset
312.82 Conduct Disorder, Adolescent Onset
313.81 Oppositional Defiant Disorder
299.80 Asperger’s Disorder
300.00 Anxiety Disorder NOS
300.01 Panic Disorder without Agoraphobia
300.02 Generalized Anxiety Disorder
314.00 ADD, Attention Deficit Disorder Inattentive
314.01 ADHD Combined
300.21 Panic Disorder with Agoraphobia
300.22 Agoraphobia
300.23 Social Phobia (Anxiety Disorder)
300.40 Dysthymia
Seasonal Affective Disorder
300.3 Obsessive Compulsive Disorder
Other __________________________________
AXIS I – CHEMICAL DEPENDENCY DISORDERS
303.0__ Alcohol Dependence/Intoxication
303.90 Alcohol Dependence
304.0__ Drug Dependence
304.0__ Opioid Dependence
304.1__ Sedative, Hypnotic, Anxiolytic Dependence
304.2__ Cocaine Dependence
304.3__ Cannibus, NOS
304.4__ Amphetamine Dependence
304.5__ Hallucinogen Dependence
304.8__ Polysubstance Abuse
.01 Continuous
.02 Episodic
305.0__ Non-dependent Alcohol Abuse
305.1__ Nicotine Dependence
305.2__ Cannabis Abuse
305.5__ Opioid Abuse
Modifiers for Abuse / Dependence
.03 In Remission
305.6__ Cocaine Abuse
305.3__ Hallucinogen Abuse
305.7__ Amphetamine Abuse
305.9__ Other, Mixed or Unspecified
305.4__ Sedative, Hypnotic, Anxiolytic Abuse
AXIS II – DEVELOPMENTAL PERSONALITY DISORDERS
301.40 Obsessive-Compulsive Personality Disorder
301.70 Antisocial Personality
301.83 Borderline Personality Disorder
AXIS III – MEDICAL DISORDERS
301.90 Personality Disorder, NOS
317.00 Mild Mental Retardation
Other / Specify
1. ________________________________________________________________________________________
2. ________________________________________________________________________________________
3. ________________________________________________________________________________________
4. ________________________________________________________________________________________
5. ________________________________________________________________________________________
AXIS IV – PSYCHOSOCIAL STRESSORS
Primary Support Group / Family
Social Environment / Getting Along
Educational / School
Occupational / Work
AXIS V – GAF SCORE (Estimate)
Housing
Economic / Finance
Health Services / Health Problems
Legal / Charges / Probation
C urrent: __________________ Last Year: __________________ Last Two Months: __________________
80-90 Minimal Symptoms, every day problems, good functioning
70-80 Slight impairment, temporary decrease in school work / job performance
60-70 Mild symptoms, difficulties with school, work, social interactions, meaningful relationships
8

50-60 Moderate symptoms, few friends, conflicts with peers / co-workers, panic attacks
40-50 Serious symptoms, suicidal ideations, impairment in school, work, or social
30-40 Behavior influenced by delusions or hallucinations, suicidal, inability to function, aggressive
20-30 Danger to self or others, violent, suicide preoccupation, inability to communication
10-30 Unable to function, suicide attempts
DIAGNOSIS DSM-IV Summary :
AXIS I: ________________________________________________________________________________________
AXIS II: ________________________________________________________________________________________
AXIS III: ________________________________________________________________________________________
AXIS IV: ________________________________________________________________________________________
AXIS V: __________________ Current GAF: __________________ Estimated GAF (highest past year):
READINESS / MOTIVATION TO SUSTAIN TREATMENT PARTICIPATION
1.
Yes No Client has sufficient transportation to get to clinic appointments on his / her own.
If yes, check the following: client has a vehicle client has family transport
client has a driver’s license client can walk/bike/take bus
client is capable of taking Medicaid transport
This barrier will prohibit client from treatment
Other: ______________________________
If no, check the following:
2.
Yes No Client can come to treatment weekly or bi-weekly on a regular basis.
If no, elaborate on why not.
3.
With regard to readiness and motivation to engage in treatment, this client is (check all that apply):
Guarded Open Can articulate problems Confused Lacks insight
Will likely respond to non-verbal / expressive arts Motivated Hopeless Hopeful
Resistant Parent is motivated, child is not Other: ____________________________
4.
The client acknowledges that the following barriers need to be addressed to successfully engage in treatment (check all that apply):
Language Domestic Violence Substance Abuse Medication Non-Compliance
Court Ordered Parent Ordered Poor Attitude, i.e.: ________________________
Other: ______________________________________________________________________
5.
Overall rating of likelihood of successfully engaging in treatment at this time:
Poor Moderate Good Excellent
Client’s current problem solving abilities are: very good adequate poor very limited
Elaboration on motivation/readiness for treatment:
TREATMENT RECOMMENDATIONS
9

SERVICE
Psychosocial Rehabilitation
Skills Training (to help client learn new skills)
(Must be justified and/or outlined on pages 3-6 in this assessment.)
Psychosocial Rehabilitation
Community Reintegration (to help client maintain learned skills or keep out of higher level of care)
(Must be justified and/or outlined on pages 3-6 in this assessment.)
PURPOSE/TO ADDRESS ISSUES OF: INTENSITY DURATION
Psychiatric
Health/Medical
Vocational / Educational
Financial
Social Relationships / Supports
Family Status
Basic Living Skills
(Circle)
1 X Weekly
2 X Weekly
2+ Weekly
(Circle)
1-3 years
3-5 years
5+ years
Housing
Community / Legal
Psychiatric
Health/Medical
Vocational / Educational
Financial
Social Relationships / Supports
Family Status
Basic Living Skills
Housing
Community / Legal
(Circle)
1 X Weekly
2 X Weekly
2+ Weekly
(Circle)
1-3 years
3-5 years
5+ years
Targeted Service Coordination
(formerly Case Management) To link client to community resources they can’t access independently due to symptoms
(Must be justified and/or outlined on pages 3-6 in this assessment.)
Counseling
Psychiatric
Health/Medical
Vocational / Educational
Financial
Social Relationships / Supports
Family Status
Basic Living Skills
Housing
Community / Legal
See client’s reasons for seeking services, symptoms and goals as noted in this CDA.
(Circle)
Weekly
Bi-Weekly
Monthly
(Circle)
Weekly
Bi-Weekly
(Circle)
1-3 years
3-5 years
5+ years
(Circle)
1 yr or less
1-2 years
10

Medication Management / Psychiatric
Evaluation
Partial Care
SERVICE
Developmental Services
PURPOSE/TO ADDRESS ISSUES OF: INTENSITY DURATION
Monthly 2-3 years
3+ years
See client’s reasons for seeking services, symptoms and goals as noted in this CDA.
As is medically necessary determined by nurse
(Circle)
Up to 1 yr
1 year
1- 5 yrs
5+ yrs
Ongoing
To provide a supportive environment to address skills needs of the client as detailed in this CDA.
To provide services suited to this client’s needs as noted in this CDA.
As deemed necessary by chosen agency
As deemed necessary by chosen agency
(Circle)
Up to 1 yr
1 year
1-5 years
5+ years
Ongoing
Determined by providers / client
Psychiatric Hospital
Supported Living / Residential
Psychological Testing
To stabilize client and address immediate and acute symptoms that place this client at risk, as noted in this
CDA.
To provide services suited to this client’s needs as noted in this CDA.
To support diagnosis / treatment
To confirm eligibility
Inpatient Determined by hospital
As necessary by chosen agency/ client
As required by referring agency
Determined by providers / client
Addiction Treatment To maintain/obtain sobriety
Other: _________________________
SERVICES OVERVIEW
Services client is qualified for: Therapy Med Management PSR TSC DD PC
Services client is electing to participate in at this time: Therapy Med Management PSR TSC
11

CRITERIA SPECIFIC TO PARTIAL CARE:
Intensity of need must be documented by at least one of the following criteria. Please place a checkmark by any criteria
below that are documented in the assessment(s). (16.03.10.04)
Documentation that participant is presently at risk for an out-of-home placement OR
Clinical deterioration that would lead to an out-of-home placement OR
Further clinical deterioration which would interfere with the participant’s ability to maintain current level of functioning (if this is used, then a description of the participant’s current level of functioning must also be documented).
Notes:
CERTIFICATION
This participant has a history of mental illness as outlined in this document. The client’s symptoms, as detailed in this assessment, prevent the client from functioning to the best of his or her ability. In addition, significant functional areas as detailed in this assessment severely limit this client. Without the treatment authorized by this Comprehensive Diagnostic
Assessment, this client will experience exacerbated symptoms and further decline in functionality. With continued services, it would be reasonably expected that client would become self-reliant and graduate from services.
This assessment certifies that this participant meets / does not meet the requirements in IDAPA 16.03.10 for receiving services in the Medicaid Enhanced Plan. This assessment represents the current status of this participant. The recommendations noted above accurately reflect this participant’s ability to engage in and benefit from services. The services recommended herein are medically necessary and appropriate.
Patient credibly expressed understanding of the side effects/risks/benefits of services and a willingness to comply with treatment.
__________________________________________________
Provider Signature and Credentials
________________________________
Date
__________________________________________________
Clinical Manager Signature and Credentials
ADDENDUMS:
________________________________
Date
CDA Client Questionnaire completed by the client or his/her parent, dated __________________. (Must be attached to this CDA)
CAFAS / PECFAS, dated ___________________. (Must be attached to this CDA)
SED Checklist, dated__________________ (Must be attached to this CDA)
Additional records obtained and consulted in the process of this assessment were:
H&P Dated:_______________
Other:__________________
Other:__________________
12

FOR MINORS COMPLETE CAFAS/PECFAS AND ATTACH TO THIS CDA
NOTES: The overall score is a total of all areas and must be 40 or above. To qualify, the client must have at least a 40 overall and two of the areas must indicate a 20 or above. One of those two areas must be a 20 or above in thinking, self harmful behaviors or moods
and emotions.
OVERALL CAFAS/PECFAS SCORE: _______________
School/Work Performance score____________ citing number(s) _____________
Brief explanation of score/cite specific behaviors:
Home Role Performance score____________citing number(s) _____________
Brief explanation of score/cite specific behaviors:
Community Role Performance score____________ citing number(s) _____________
Brief explanation of score/cite specific behaviors:
Behavior Toward Others score____________citing number(s) ___________
Brief explanation of score/cite specific behaviors:
(NOTE: For psychiatric, this must be score of 20 or above in thinking, self harm or moods/emotions)
Psychiatric:
Moods/Emotions score_________ citing number(s)_______________
Brief explanation of score/cite specific behaviors:
Self Harm score________ citing number(s) ________________
Brief explanation of score/cite specific behaviors:
Thinking score_________ citing number(s) _______________
Brief explanation of score/cite specific behaviors:
Substance Use score____________ citing number(s) _____________
Brief explanation of score/cite specific behaviors:
13

Client Name:______________________________ DOB:_________________________________
To qualify for enhanced therapy services the child must have a S.E.D.
(Serious Emotional Disturbance) is defined as “an emotional or behavioral disorder, or a neuro-psychiatric condition which results in a 1) serious disability, and which 2) requires sustained treatment interventions, and 3) causes the child’s functioning to be impaired in thought, perception, affect, or behavior.
PART I – DEFINING SERIOUS DISABILITY
Does the child participant have a condition exhibiting one or more of the following characteristics over a long period of time and to a marked degree, which adversely affects educational performance?
An inability to learn which cannot be explained by health, sensory, or intellectual factors
An inability to build or maintain satisfactory relationships with peers and teachers
Inappropriate types of behavior or feeling under normal circumstances
A general pervasive mood of unhappiness or depression
A tendency to develop physical symptoms or fears associated with personal and school problems
As defined by the IDEA (Individuals with Disabilities Act):
SED includes children who are schizophrenic or autistic. It DOES NOT apply to children who are socially maladjusted, unless it is determined that they have/meet the above criteria for SED.
Current Diagnosis: (P)________________________________________
PART II
Please expand briefly on the above checked criteria (including symptoms, frequency, duration, and severity) that justify enhanced clinic services.
___________________________________________ _______________
Date Clinician signature and credentials
* Please Attach To CDA or CDA Amendment form.
14

IDHW H0002
Directions: Please fill in all blanks, print and sign the form, submit to the Idaho Falls Processing Center by fax at
208-528-5933 or 888-532-0014. You may choose to submit the form electronically to: HCCR7@dhw.idaho.gov
Maintain original in participant’s record.
IDENTIFYING INFORMATION
Name of Participant:___________________________________ Medicaid ID#:_________________
Riverside REHAB, Inc. Provider Numbers: 804259300, 805559100, NPI 1922167279
Name of Provider Certifying Medicaid Enhanced Plan: ___________________________________________
(Please print)
Agency Phone # (208) 853-8536 Agency Fax # (208) 853-2929
RATIONALE FOR ENHANCED PLAN SERVICES
(Provider: please check the appropriate box as indication of the justification for this participant needing the Medicaid
Enhanced Plan)
Participant needs the following services:


Additional Psychotherapy
Partial Care
 Service Coordination
 Developmental Disabilities
 Psychosocial Rehabilitation  Inpatient Psychiatric Hospitalization
CERTIFICATION
I have assessed ____________________________________on ______________and certify that this
(Name of participant) (date) participant meets the requirements in IDAPA 16.03.10 for receiving the above indicated services in the Medicaid Enhanced Plan. Please start enhanced services effective __________________.
________________________________________________________________________________
Signature of Provider Certifying Participant’s Eligibility Date
Please contact us at 1-888-528-5861 or 528-5877 or 528-5866 if you have any questions.
Rev. 02/08
15