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Statistics and Publications

Forms

Archived Forms

Audit Forms

• 2011 Spring Targeted Case Management Audit
  • MH/SA TCM Audit Tool
  • MH/SA TCM Eligibility Checklist
  • MH/SA TCM Continued Eligibility Checklist
  • MH/SA TCM Qualifications Checklist
  • I/DD TCM Audit Tool (updated 2/21/11)
  • I/DD Qualifications Checklist (new)
• 2010 Fall Medicaid Audit
  • Medicaid Services Audit Tool
  • Crisis Plan Review Tool
  • ACTT Composition and Qualifications Checklist
  • CST Composition and Qualifications Checklist
  • PSR Qualifications Checklist
• 2009/2010 SA/MH Block Grant Review
  • MAJORS
  • CASAWORKS Individual
  • CASAWORKS Program
  • Community MHBG Individual
  • Community MHBG Program
  • WorkFirst Program
  • Safe Drug-Free Schools Individual
  • Safe Drug-Free Schools Program
  • SAPTBG Individual
  • SAPTBG Program IV Drug Users
  • SAPTBG Program Pregnant Women/Children
  • Women Set Aside
  • Work First Individual
  • SAPTBG Prevention (1/21/10)
• 2010-2011 DWI Audit
  • DWI Review Tool 1 - Administration/Operations
  • DWI Review Tool 2 - Assessments/e508
  • DWI Review Tool 3 - Treatment/ADETS
  • Review Findings and Exit Form

Contact Logs

• Individual Group Contact Log A
• Individual/Group Contact Log B
• Contact Log A
• Contact Log B

Criterion 5

• Criterion 5 Contract-State Hospital
• Criterion 5 Contract-Private Hospital

Forms for Facilities

• Authorization to Disclose Health Information DHHS-1000 (8/03)
• Provider Participation in Consultation Form
• Legal Forms for Hospitals
  • Emergency Certificate 5-72-01A
  • Examination and Recommendation to Determine Necessity for IVC 5-72-09
  • Evaluation for Voluntary Admission/Continued Stay 5-73-01
  • Request for Hearing 5-76-01
  • Commitment Change 5-79-01
  • Request for Return 5-82-02
  • Notice of Return 5-83-01

For court forms for commitment, go to the AOC website at www.nccourts.org

Incident Response and Improvement System (IRIS)

• QM11 Provider Quarterly Incident Report (rev 10/10) Word
• QM04 DHHS Restrictive Intervention Detail (11/04)

Involuntary Commitment Forms

• Emergency Certificate 5-72-01A
• Examination and Recommendation to Determine Necessity for IVC 5-72-09

For court forms for commitment, go to the AOC website at www.nccourts.org

LME Forms

• SFY 11 LME Performance Contract Reports/Data Requirements (1-20-12)
• SFY 11-12 Local Management Entity (LME) Semi-Annual Substance Abuse Prevention and Treatment Block Grant (SAPTBG) Compliance Report (1/3/12)
• Customer Service Form (1/13)
• Quarterly Complaint Form (1/13)
• LME Consumer Admission and Discharge Form (7/9/10)
• LME Report of Access, Triage and Referral for Emergent, Urgent and Routine Care Form (7/1/10)
  • Memo
• Notification of Endorsement Action (NEA Form Letter)
• Notification of Out of Home community Placement for Children/Adolescents
• Out of State Placement of a Child Form
• Service Note D
• Standardized Consumer Interview and Registration (STR) Form (12/31/08)
• TBI - LME Application for Individuals (Word) 6/25/09
• TBI - LME Application for Entities (Word) 6/25/09
• LME RFA memo
  • HB1473 RFA (9/07)
  • RFA Attachment 1
  • RFA Attachment 2
  • Utilized Bed Days Reports for rates by LME (8/31/07)

Financial Form

• IPRS Rate Request Form (10/09)

Medicaid Form

• Outpatient Treatment Record
  • Instructions

Miscellaneous Forms

• ValueOptions Outpatient Review Form (ORF2)
• ValueOptions Inpatient Review Form (ITR)
  • Instructions
• Work First/CPS/SA Reporting Form (Word) 9/09

NC-SNAP Form

• NC-SNAP Summary Report and Supplemental Information (6/10)

NCTOPPS Forms

• Mental Health/Substance Abuse Adult
  • Initial
  • Update
  • Episode Completion
  • Recovery Follow-up (post treatment follow-up interview)
• Mental Health / Substance Abuse Adolescent
  • Initial
  • Update
  • Episode Completion
  • Recovery Follow-up (post treatment follow-up interview)
• Mental Health Child

• Initial
• Update
• Episode Completion
• Recovery Follow-up (post treatment follow-up interview)

Forms in Spanish

• Programa de área/condado /MEMBRETE DE LME
• Notificación de la resolución de UM por servicio no perteneciente a Medicaid
• AUTORIZACIÓN Y ACEPTACIÓN PARA AUDIENCIA NO PERTENECIENTE A Medicaid
• FORMULARIO DE SOLICITUD DE APELACIÓN NO PERTENECIENTE A MEDICAID
• Carta de solicitud de apelación de un beneficiario no perteneciente a Medicaid
• Formulario de queja por servicio no perteneciente a Medicaid
• Notificación de la resolución de UM por servicio no perteneciente a Medicaid

CAP-MR/DD Forms

DWI Forms

Person Centered Planning (PCP) Forms

Provider Endorsement Forms

 

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