• MH/DD/SAS Home

• About Us
• Acronyms
• A-Z Topics
• Contacts

 

Statistics and Publications

Provider Endorsement Information: Checksheets and Forms

Checksheets

Adult Mental Health

• Psychosocial Rehabilitation (PSR) (1/11)
  
  • Checksheet
  • Instructions
  • Daily Note Guide

Adult Mental Health/Substance Abuse

• Community Support Team (1/1/11)
  
  • Checksheet
  • Instructions
• Facility Based Crisis Services (1/11)
  • Checksheet
  • Instructions

All

• Diagnostic Assessment (1/11)
  • Checksheet
  • Instructions
• Mobile Crisis (1/11)
  • Checksheet
  • Instructions
• Clinical Interview (1/11)
  • Checksheet
  • Guidelines
  • Question Provider Handout

Child Mental Health

• Child Residential Level II (1/11)
  • Checksheet
  • Instructions
• Child Residential Level III (1/11)
  • Checksheet
  • Instructions
• Child Residential Level IV (1/11)
  • Checksheet
  • Instructions
• Multi-Systemic Therapy (MST) (1/11)
  • Checksheet
  • Instructions
• Day Treatment (1/1/11)
  
  • Checksheet
  • Instructions

Child Mental Health/Substance Abuse

• Intensive In-Home (1/11)
  • Checksheet
  • Instructions

Mental Health

• Partial Hospitalization (1/11)
  • Checksheet
  • Instructions

Mental Health/Substance Abuse

• Assertive Community Treatment Team (ACTT) (1/11)
  • Checksheet
  • Instructions
• Community Support: Adult (10/07)
  • Checksheet
  • Instructions
• Community Support: Child (10/07)
  • Checksheet
  • Instructions
    

MR/DD

• Targeted Case Management (1/11)
  • Checksheet
  • Instructions
    

Substance Abuse

• Detox Services: Ambulatory (1/11)
  • Checksheet
  • Instructions
• Detox Services: Medically Supervised/ADATC (1/11)
  • Checksheet
  • Instructions
• Detox Services: Non-Hospital Medical (1/11)
  • Checksheet
  • Instructions
• Opioid Treatment (1/11)
  • Checksheet
  • Instructions
• Substance Abuse Comprehensive Outpatient Treatment (SACOT) (1/11)
  • Checksheet
  • Instructions
• Substance Abuse Intensive Outpatient (SAIOP) (1/11)
  • Checksheet
  • Instructions
• Substance Abuse Medically Monitored Community Residential (1/11)
  • Checksheet
  • Instructions
• Substance Abuse Non-Medical Community Residential (1/11)
  • Checksheet
  • Instructions
    

CAP-MR/DD Waiver Services

• CAP-MR/DD Crisis Respite (7/10)
• Checksheet
• Instructions
• CAP-MR/DD Behavioral Consultant (7/10)

• Checksheet
• Instructions
• CAP-MR/DD Respite (1/11)
  • Checksheet
  • Instructions
• Adult Day Health (1/11)
  • Checksheet
  • Instructions
• Crisis Services (1/11)
  • Checksheet
  • Instructions
• Day Supports (1/11)
  • Checksheet
  • Instructions
• Home and Community Supports (1/11)
  • Checksheet
  • Instructions
• Home Supports (2/11)
  • Checksheet
  • Instructions
• Personal Care Services (1/11)
  • Checksheet
  • Instructions
• Residential Supports (1/11)
  • Checksheet
  • Instructions
• Specialized Consultative Services (1/11)
  • Checksheet
  • Instructions
• Supported Employment (1/11)
  • Checksheet
  • Instructions
• Vocational Support (1/11)
  • Checksheet
  • Instructions

Forms

• Standardized Credentialing Application (7/12)
• CABHA Site Attestation Letter (9/11)
• Site Attestation Letter (4/11)
• Business Entity Verification Renewal Letter (4/11)
• Notification of Endorsement Action (NEA Form Letter) (7/10)
• CSS Provider Contested Case Form (09/08)
• MOA between LME and Provider (5/15/06)
• Provider Endorsement Appeal Policy (4/6/06)
• Core Rules Self Study (8/05)
• Notification of State of Application Information (7/05)

 

Return to top