Region 10 PIHP Forms

Region 10 PIHP offers an array of forms.  Forms may be available in alternative versions.  Please contact Region 10 PIHP to request alternative form versions. 

Chapter 1: Administrative Policy Forms

Chapter 2: Human Resources Policy Forms

Personnel


None

Chapter 3: Information Management Policy Forms

Technology


None

Data Management


None 

Health Records


03.01.05 Information System Security

PDF DocumentRegion 10 PIHP Computer Acceptable Use Agreement
PDF DocumentMIX Software Enrollment Request Form

03.03.03 Behavioral Health Consent Form  

PDF DocumentMDHHS-5515 Consent to Share Behavioral Health for Care Coordination Purposes

Chapter 6: Health and Medical Policy Forms

Health Care


None  

Chapter 7: Rights of Persons Served Policy Forms

Individual Rights


07.01.03 Sentinel Events Critical Incidents and Risk Events

PDF DocumentRegion 10 Sentinel Event Review Committee Summary Form

Grievances and Appeals 


None

Substance Use Disorder (SUD) Forms

Substance Use Disorder (SUD) related forms are organized by category and are listed below for your reference.

Finance


PDF DocumentAbility to Pay Administrative Hearing by Telephone
PDF Document
Ability to Pay Administrative Hearing Disposition Form
PDF DocumentAbility to Pay Administrative Hearing Notice
PDF DocumentAbility to Pay Administrative Hearing Request
PDF DocumentAudit Exemption Letter
PDF DocumentDetermination of Taxable Income
PDF DocumentFinancial Information & Payment Agreement/Sliding Fee Scale
PDF DocumentFiscal Year 2018 Provider Services Cost Summary
*Microsoft Excel version available for Fiscal Year 2018 Provider Services Cost Summary.
PDF Document Fiscal Year 2018 Unbilled SUD Services 
*Microsoft Excel version available for Fiscal Year 2018 Unbilled SUD Services. 
PDF DocumentGuidelines for Inclusion & Exclusion of Assets, Income and Expenses
PDF DocumentNew Determination
PDF DocumentNotice of Outcome of Ability to Pay Administrative Hearing
PDF DocumentNotice of Rights for Ability to Pay
PDF DocumentProvider ACH Vendor Authorization
PDF DocumentProvider Budget Detail
*Microsoft Excel version available for Provider Budget Detail.
PDF DocumentRegion 10 Provider Financial Status Report 
*Microsoft Excel version available for Region 10 Provider Financial Status Report.
PDF DocumentRequest for a New Rate Determination
PDF DocumentRequest to Reduce or Waive Assessed Fee
PDF DocumentW-9 Request for Taxpayer Identification Number and Certification

Naloxone


PDF DocumentNaloxone Monthly Report
PDF DocumentNaloxone Registration Form - General
PDF DocumentNaloxone Registration Form - Law Enforcement
PDF DocumentNaloxone Registration Form - SCCHD
PDF DocumentNaloxone Registration Form - Wellness  
PDF DocumentOverdose Prevention & Naloxone Use Report

Prevention


PDF DocumentPrevention Contract Amendment Proposal
PDF DocumentPrevention Program Fee Report
PDF DocumentPrevention Providers Staffing Roster  
PDF DocumentPrevention Satisfaction Survey  
PDF DocumentPrevention Services Outcome Evaluation Report
PDF DocumentPrevention Services Work Plan

Other


PDF DocumentBH TEDS Data Sheet
PDF DocumentTraining Requirements Grid