Access and Registration Procedures

• ADATC Referral 12/07 (PDF) (Word)
• ADATC Rehab Ref Form 041807 (PDF) (Word)
• Assignment of Case Responsibility/1st Responder - Spanish (ACR - replaced by ERF 5/3/12) (PDF) (Word)
• Assignment of Case Responsibility/1st Responder - English (ACR - replaced by ERF 5/3/12) (PDF) (Word)
• Description of Consumer Clinical Issues form 04/13/12 (PDF) (Word)
• Enrollee Registration Form (ERF) 4/3/12 (PDF) (Word)
• Enrollee Registration Form - Spanish (ERF) 4/3/12 (PDF) (Word)
• LME Consumer Admission and Discharge Form (07/01/10) (PDF) (Word)
• Medicaid Enrollee Registration Form (MERF - replaced by ERF 5/3/12) (PDF) (Word)
• Medicaid Enrollee Registration Form - Spanish (MERF - replaced by ERF 5/3/12) (PDF) (Word)
• Medicaid Referral Form - MOA Providers (Word)
• Regional Assessment & Referral Form (RARF) 12/30/11 (PDF) (Word)
• STR Registration Form (12/31/08) (PDF) (Word)
• Treatment Authorization Request Form (TAR) begin using 1/3/12 (PDF) (Word)

Career Opportunities

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

Claims and Reimbursements

• 835 Request Form (PDF) (Word)
• CAP-MR/DD Supply/Equipment Receipt and Authorization Confirmation Form (PDF) (Word)
• CCIS User Assignment Request (PDF)
• Claims Resolution Inquiry (PDF) (Word)
• CMS-1500 (formerly HFCA-1500) Health Insurance Claim Form. Re-posted 2/16/07 (PDF)
• EFT Authorization Agreement (PDF) (Word)
• Medicaid Direct Enrolled Provider Billing Registration Application (04/02/08) (PDF) (Word)
• NPI Collection Form Oct 2010 (Excel)
• State Funding Eligibility Statement 11/01/11 (PDF) (Word)
• Trading Partner Agreement (PDF)

Consumer & Family Advisory Committee (CFAC)

• Advance form (PDF)
• CFAC Bylaws Sept 2011 (PDF) (Word)
• CFAC Membership Application (PDF) (Word)
• CFAC Reimbursement Form (PDF) (Word)
• CFAC Relational Agreement with the Board (PDF) (Word)

Crisis Planning

• Crisis Planning Worksheet (PDF) (Word)

Incident Reporting Forms & Documents

• QM11 [Revised Oct 2010] (Word)

IPRS Target Population

• IPRS Target population (PDF)

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)

Service Authorization Procedures (UM)

• Enrollee Registration Form (ERF) 4/3/12 (PDF) (Word)
• Enrollee Registration Form - Spanish (ERF) 4/3/12 (PDF) (Word)
• Medicaid Enrollee Registration Form (MERF - replaced by ERF 5/3/12) (PDF) (Word)
• Medicaid Enrollee Registration Form - Spanish (MERF - replaced by ERF 5/3/12) (PDF) (Word)
• Notification Form Out Of Home Community Placement (PDF) (Word)
• PRTF Cert. of Need (PDF)
• Reauthorization For Continued Stay (PDF) (Word) (.DOCX)
• Regional Assessment & Referral Form (RARF) 12/30/11 (PDF) (Word)
• Service Authorization Request Form (SAR) - replaced by TAR 1/3/12 (Word)
• State Funding Eligibility Statement 11/01/11 (PDF) (Word)
• Treatment Authorization Request Form (TAR) begin using 1/3/12 (PDF) (Word)

Western Highlands Network Board

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