The requirement for Physician directed services has been added to this manual.  This requirement will place an extraordinatory burden on the CSB's when we are already faced with a workforce shortage in psychiatry.  If this language remains it will result in increased barriers to care and limited access at a time when the state is encouraging initiatives that improve access..  There is barely sufficient psychiatry and/or nurse practitioner availability in the rural areas of our state to meet the medication needs for those we serve.  I encourage you to strongly reconsider this requirement in this manual.