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. And if this must stay, it does not appear to allow us the ability to provide even three sessions or thirty days (whichever is soonest) before the F2F evaluation  I encourage you to strongly reconsider this requirement in this manual.