Forms

Prevention

MPDS User Activation/Deactivation Form

MPDS User Manual

Finance and Claims

Income Eligibility and Fee Determination Waiver Worksheet

MSHN Budget Template

MSHN Budget Instructions

REMI

Provider Portal

Grievance Forms

Grievance Submission Form

Medicaid Fair Hearing Forms

Medicaid Fair Hearing Form

Medicaid Fair Hearing Withdrawal Form

Advance Directives

Advance Directives Brochure

Breach Notification

Breach Notification Template

Credentialing and Recredentialing

Application for Organizational Credentialing - Initial

Application for Organizational Recredentialing

Attachment A - Staff Training Information

Attachment B - Professional Liability Detail

Attachment C - Disclosure of Ownership & Controlling Interest

Attachment D - Electronic Funds Transfer

ASAM Level of Care Initial Enrollment

Outpatient (0.5, 1.0, 2.1, 2.5)

Outpatient Provider Enrollment Process

Outpatient Completion Guidelines

Outpatient Enrollment Application

Residential (3.1, 3.3, 3.5, 3.7)

Residential Provider Enrollment Process

Residential Completion Guidelines

Residential Enrollment Application

Withdrawal Management (1-WM, 2-WM, 3.2-WM, 3.7-WM)

Withdrawal Management Provider Enrollment Process

Withdrawal Management Completion Guidelines

Withdrawal Management Enrollment Application

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

Outpatient (0.5, 1.0, 2.1, 2.5)

Outpatient Completion Guidelines

Outpatient Enrollment Application

Residential (3.1, 3.3, 3.5, 3.7)

Residential Completion Guidelines

Residential Enrollment Application

Withdrawal Management (1-WM, 2-WM, 3.2-WM, 3.7-WM)

Withdrawal Management Completion Guidelines

Withdrawal Management Enrollment Application

Consent to Share Behavioral Health Information Forms

Consent to Share Behavioral Health Information

FAQ Document for Providers

FAQ Document for Individuals

Provider Network Forms

Provider Appeal Form

Community Health Worker Attestation Form