Endorsement Forms & Documents

If you need assistance:

Please contact a Provider Specialist in the Provider & Consumer Relations Department at 828-225-2785 or 1-800-671-6560 or contact the appropriate Provider Specialist listed on our Provider and Consumer Relations Page.

Available online documents:

Open them directly by clicking on them, or save them to disk (the easiest way on a PC is by right-clicking your mouse.) The files are in Word 2000, Excel 2000 and Adobe Acrobat 5.0 PDF files. Each document link is set to open in a new window.

For the most current endorsement information and documents please visit the Endorsement Section of the Division of Mental Health, Developmental disabilities and Substance Abuse Services website:http://www.ncdhhs.gov/mhddsas/stateplanimplementation/providerendorse/index.htm

Division of Medical Assistance (DMA) Enrollment Applications can be downloaded from the DMA website at http://www.nctracks.nc.gov/provider/providerEnrollment/index.jsp. Please note: This is the same application that is required to initiate the endorsement process with Western Highlands Network.

To report a Change in Provider Status review the DMA Change Matrix at http://www.nctracks.nc.gov/provider/cis.html.  Changes should be reported to DMA as indicated within this Matrix.  Copies of this documentation needs to be submitted to WHN for all endorsed site/services.