Application for Residential Treatment Center – Family

This form must be filled out by you (the parent or legal guardian) in order to have your child placed in a Residential Treatment Center. Fax the application to Health Net Federal Services, LLC (Health Net) at 1-877-809-8667. You can also have your doctor send the form for you.

Health Net will look at the request once we receive both your family application and your doctor application.

  • Created: Mar 11, 2016
  • Modified: Mar 11, 2016
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