Form P45 — USA v. Jittaphol (Dkt. 34.3)

Summary

Form 45, Initial Treatment Services Contract Program Plan, Case 1:21-cr-10270-MLW, Document 34-3. The plan names Aticha Jittaphol as the client, Maureen Curran as the officer, and Behavioral Health Network, Inc. as the provider, with an effective date of 12/01/2021. The services ordered are Inpatient Detox-Medical, Short-term Residential Treatment, and Long-Term Residential Treatment, each with a copay amount of $0.00 per unit. It states that services outside the listed services or the effective and termination dates will not be authorized for payment. The page prints the signature text /s/ Maureen Curran, /s/ Christopher Foster and /s/ Aticha Jittaphol.

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Case 1:21-cr-10270-MLW Document 34-3 Filed 01/28/22 Page1ofi1

Prob. Form 45
Today's Date: 12/1/21

Initial

TREATMENT SERVICES CONTRACT PROGRAM PLAN
Client Identifying Information

Client: Jittaphol, Aticha PACTS #: 7669091
Address: 64 Brighton Avenue Pretrial/Post Pretrial
#311 Conviction:
Brighton MA 02134
Officer: Curran, Maureen Client Phone: 6178697865
Officer Phone: 617-655-2818 DOB: 01/15/1989

Provider Information

Provider: Behavioral Health Network, Inc. Procurement No: 0101-2021-IP3A
(IP)

Provider Location: Behavioral Health Network, Inc. Effective Date: 12/01/2021
(IP)

Attn: Lorie Pastrana Termination Date:

Location Address: 417 Liberty Street
Springfield MA 01104

Phone: (413) 333-9753

Fax: (413) 846-4806

Authorized Services

Your agency is authorized to provide the following services beginning on the plan effective date indicated above. Any services provided
outside of those listed below and/or outside the Effective and Termination Dates of the Plan will not be authorized for payment.

Services Ordered
ProjectCode Description Of Services Phase Frequency (Units) Interval Copay Amount
(per unit)
8010 Inpatient Detox-Medical 7.0 Per Plan $0.00
Detox
2001 Short-term Residential 14.0 Per Plan $0.00
Treatment
2002 Long-Term Residential 31.0 Monthly $0.00
Treatment
Instructions to Provider Regarding Client Needs and Goals of Treatment
/s/Maureen Curran /s/Christopher Foster /s/Aticha Jittaphol
Officer: Curran, Maureen Referral Agent: : Foster, Client: Jittaphol, Aticha

Christopher

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