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Manuals and Forms

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Welcome to the Manuals and Forms page

Below are listed DMH/DD/SAS' most commonly used manuals and forms. Download whatever you need. Documents are available in Acrobat Format and sometimes, Word format.

If the manual and/or form you seek is not listed, email us with your request.

Manuals | Forms

Manuals

Group Home Licensure Manuals (Rules Needed for Facility Licensure). The four manuals below contain rules and are required for group home licensure (you may download the pages for free or click here to purchase them as prepared booklets with a check or money order, only).

  1. Rules for MH/DD/SA Facilities & Services
    APSM 30-1     (10/07) (Includes Administrative Rules for Substance Abuse Services / DWI Offenders)
  2. Confidentiality Rules
    APSM 45-1     (1/05)
  3. Client Rights Rules in Community Mental Health, Developmental Disabilities & Substance Abuse Services
    APSM 95-2     (7/03)
  4. Records Management and Documentation Manual for Providers of Publicly-Funded MH/DD/SAS, CAP-MR/DD Services and Local Management Entities | Appendices | RMD Appendix D (Word Version) APSM 45-2 (10/07) (Because of the large size of the new manual, it has been separated into two parts. Be sure to print out both the manual and the appendices.) Outline of Changes Memo (10/07) New Implementation Date for Records Management and Documentation Manual (10/29/07)

Incident and Death Response System.

  1. Memo- QM02 Update (9/20/07)
  2. Form- QM02 DHHS Incident and Death Report (3/06
  3. Memo- Incident and Death Reporting Changes (2/06) | Instructions- QM13 Instructions (rev 1/06)
  4. Form- QM13 LME Quarterly Incidents Reports (1/06)
  5. Form- QM11 Provider Quarterly Incident Report (rev 1/06)| Instructions- QM02 Changes (1/06)
  6. Form- QM13 LME Quarterly Incidents Reports (1/06)
  7. Manual- Incident and Death Response System Manual (11/04)
  8. Form- QM04 DHHS Restrictive Intervention Detail (11/04)

Other Administrative Publication System Manuals (APS) (in alphabetical order by name):

Area Programs Budget Procedures Manual Revised Record
APS-M 75-1 (7/95)

CDW Data Dictionary V1.9 (Eff. 10/01/08)
CDW Reporting Requirements V 1.11 (Eff. 10/1/08)
Update to CDW Reporting Requirements Memo (6/12/08)

CDW Data Dictionary V1.7 (Eff. 7/1/06) | CDW Reporting Requirements V1.9 (Eff. 7/1/06)
CDW Data Dictionary V8 (Eff. 5/1/08)
CDW Reporting Requirements V1.10 (Eff. 5/1/08)
CDW Reporting Requirements Memo (2/8/08)

Human Rights for Clients in State Facilities
APS-M 95-1 (7/03)

Medicaid Service Guidelines
APS- (7/99)

New Service Definitions (Updated 3/27/06)
Division of Medical Assistance Clinical Coverage Policy No: 8A Enhanced Mental Health and Substance Abuse Services (Revised Date: February 1, 2008; Effective March 1,2008) | Old Service Definitions Manual
APS-M 1026 (1/03)

Policy on Placement of Long Stay Patients
APS-R 110-12 (approved 8-23-06) (replaces APS-R 110-12 Discharge Policy

Records Retention and Disposition Schedule for Central and Regional Offices of Division of Mental Health, Mental Retardation and Substance Abuse Services
APS-M 10-4 (10/1/86)

Records Retention and Disposition Schedule for State and Area Facilities
APS-M 10-3 (10/04 updated 5/05)

Reporting and Approval of Research Agreements
APS-R 65-1 (7/1/87)

Standards for Monitoring & Accreditation of Area Programs
APS-M 40-3 (5/98)

Forms
(in alphabetical order by name of form)

Name of Form
Associated Materials
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Authorization for Release of Confidential Information (DHHS-1000)

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CAP-MR/DD Unlicensed AFL Health and Safety On-Site Review form  
  Guidelines on Conducting Self Audit for Community Supports Providers (2/6/08)
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Customer Service Form (Word doc posted 10-9-06) and Quarterly Complaint Report Form (posted 8-7-07; updated 5/16/08)

LME Complaint Reporting: Guidelines for Customer Service Form and Quarterly Complaint Report

Complaint Reporting Quarterly Review Instructions

LME Complaint Reporting Memo from Mike Moseley (dated 9-8-06)
Hospital/ADATC Regional Referral Admissions Authorization Memo

Hospital/ADATC Regional Referral Admissions Authorization Form

DMH1-73-00 (rev12/07)
a
IPRS rate Request Form (11/07)  
Legal Forms for Hospitals

5-72-01 Examination and Recommendation to Determine Necessity for Involuntary Commitment
5-72-01A Certificate
5-72-01B Certificate Supplement
5-73-01 Evaluation
5-76-01 Request for Hearing
5-79-01 Commitment Change
5-82-02 Request for Return
5-83-01 Notice of Return

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LME Consumer Admission and Discharge Form (6/2/08)  
LME/Provider Operations Manual (4/22/05)  

HB1473 RFA 9-07
RFA Attachment 1
RFA Attachment 2

Utilized Bed Days Report for rates by LME 8-31-07 Rev.

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NC-TOPPS SFY 2007 – 2008 Implementation Guidelines  
Non-Medicaid Appeal Process Documents Translated into Spanish Memo
Posted 2/27/07
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Person Centered Planning (PCP) Forms

 
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Psychiatric Hospital/ADATC Regional Referral Admissions Authorization Memo Psychiatric Hospital/ADATC Regional Referral Admissions Authorization Form DMH1-73-00 (rev12/07)
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STR (Interview and Registration) Form: Standardized Consumer STR Interview and Registration Form (6/2/08) Memo regarding STR Admission and Discharge
TBI State Funds Request by LMEs Form (6/07)  
ValueOptions
Outpatient Review Form (ORF2)		  

ValueOptions Inpatient Report (ITR)

 Instructions
Uniform Screening and Registration | Word Version (fill out on computer) Word Version (print and fill out) of Registration Form
a
Work First/CPS/SA Reporting Form 12/07  

 

 

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Updated November 4, 2008

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