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Translate:
PROVIDER FORMS
Authorization to Order-Pay Form
Connectivity Request Form
(Citrix/ CMHC connection; New Web-based form)
Connectivity Termination Form
(formerly
New Hire/ Termination
form)
Connectivity Termination Web Form
(formerly
New Hire/Termination
form)
Consumer STR Interview and Registration Form
DHHS Incident and Death Report
LME Consumer Admission & Discharge Form
Monthly Attendance Sheet 1-15
Monthly Attendance Sheet 16-31
Notification of Out of Home Community Placement
Person Centered Plan Forms
Service Auth Request Form
Statistical Change Form
Required Network Provider Criteria Attachment Corporate Application
Required Network Provider Criteria Attachment Form A
Required Network Provider Criteria Attachment Form B
FOR HELP IN A CRISIS
OR
TO ACCESS SERVICES
CALL:
1-877-327-2593 (toll free)
TDD/Hearing Impaired: 828-325-4698
Empowering People ~ Strengthening Community
