Forms

Prevention

MCBAP CEU Form 


 

Finance and Claims


REMI




Credentialing and Recredentialing

Temporary Privileging Form (for provider staff)


ASAM Level of Care Initial Enrollment

Outpatient (0.5, 1.0, 2.1, 2.5)
 
Residential (3.1, 3.3, 3.5, 3.7)
Withdrawal Management (1-WM, 2-WM, 3.2-WM, 3.7-WM)
 

ASAM Level of Care Re-Enrollment (every two years)‚Äč 

Outpatient (0.5, 1.0, 2.1, 2.5)
 
Residential (3.1, 3.3, 3.5, 3.7)
 
Withdrawal Management (1-WM, 2-WM, 3.2-WM, 3.7-WM)
 

Consent to Share Behavioral Health Information Forms

 

Provider Network Forms

Provider Appeal Form