Access and Registration Procedures

• Assignment of Case Responsibility/1st Responder (Spanish) (PDF) (Word)
• Assignment of Case Responsibility/1st Responder (English) (PDF) (Word)
• Description of Consumer Clinical Issues form 092107 (PDF) (Word)
• LME Consumer Admission and Discharge Form (12/31/08) (PDF) (Word)
• STR Registration Form (12/31/08) (PDF) (Word)

CAP MR/DD Information

• CAP MRDD Uniform Portal Prioritization Form (Word)
• CAP MRDD Uniform Portal Prioritization Form with Instructions (PDF)

Career Opportunities

• Application, Employment Form PD-107 (PDF) (Word)
• Application, Employment Form Supplemental PD-107a (PDF) (Word)

Consumer & Family Advisory Committee (CFAC)

• Advance form (PDF)
• CFAC Membership Application (PDF) (Word)

Crisis Planning

• Crisis Planning Worksheet (PDF) (Word)

Developmental Disabilities Forms & Documents

• CAP MRDD UP Priority Form (Word)
• Uniform Portal Process (Word)

Incident Reporting Forms & Documents

• QM11 0106 (Word)

IPRS Target Population

• IPRS Target population (PDF)

Performance Monitoring

• Plan Corrective Action Submit Form (PDF) (Word)
• Post Payment Review Plan of Corrective Action (Word)

Person Centered Plan (PCP)

• Basic Benefit PCP (PDF) (Word)
• Complete PCP (PDF) (Word)
• Getting it Right Form (PDF) (Word)
• PCP Learning Log (PDF) (Word)
• PCP Update/Revision (PDF) (Word)
• Update/Revision Signatures (PDF) (Word)

Provider Information

• Agency Provider Profile (PDF) (Word)
• Agency Referral Information Form (PDF) (Word)
• Provider Training Registration Form (Word)

Reimbursement and Claims

• CAP-MR/DD Supply/Equipment Receipt and Authorization Confirmation Form (PDF) (Word)
• CCIS User Assignment Request 11/28/07 (PDF)
• Claims Resolution Inquiry (PDF) (Word)
• CMS-1500 (formerly HFCA-1500) Health Insurance Claim Form. Re-posted 2/16/07 (PDF)
• Medicaid Direct Enrolled Provider Billing Registration Application (04/02/08) (PDF) (Word)
• NPI Collection Form V 1 (Excel)
• Provider Funding Request Form (PDF) (Word)
• Request to Change MRA (PDF) (Word)
• State Funding Eligibility Statement 01/25/08 (PDF) (Word)

Service Authorization Procedures (UM)

• ACTT Eligibility Checklist (PDF) (Word)
• ACTT Step Down Worksheet (PDF) (Word)
• ADATC Referral 12/07 (PDF) (Word)
• Assignment of Case Responsibility/1st Responder (Spanish) (PDF) (Word)
• Assignment of Case Responsibility/1st Responder (English) (PDF) (Word)
• Authorization Tracking Form (PDF) (Word)
• LME Consumer Admission and Discharge Form (12/31/08) (PDF) (Word)
• Notification Form Out Of Home Community Placement (PDF) (Word)
• Notification Form (Child) 11/03 (PDF) (Word)
• PRTF Cert. of Need (PDF)
• Room & Board Form (PDF) (Word)
• Service Authorization Request Form (SAR) (Word)
• State Funding Eligibility Statement 01/25/08 (PDF) (Word)
• STR Registration Form (12/31/08) (PDF) (Word)

Western Highlands Network Board

• Advance form (PDF)
• Application, Human Rights Committee (Word)
• Application, QIC SPC Committee (Word)