Forms

Prevention

MPDS User Activation/Deactivation Form 

MPDS User Manual 


Finance and Claims

 

REMI

Appeal Forms


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