Region 10 PIHP Forms

 

substance abuse disorder


Word DocumentBH TEDS Data Sheet

Excel DocumentFY 2016 Unbilled SUD Services Form

PDF DocumentInjecting Drug Users 90% Capacity Treatment Report

PDF DocumentLevel of Care Change Request

Excel DocumentNaloxone Cumulative Data

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 DocumentNaloxone Use Report

PDF DocumentPrevention Contract Amendment Proposal

PDF DocumentPrevention Outcomes Report

PDF DocumentPrevention Program Fee Report  

PDF DocumentPrevention Satisfaction Survey  

Word DocumentPrevention Services Work Plan

Excel DocumentPrevention Quarterly Report

Word DocumentPrevention Staffing Roster 

Excel DocumentProvider Budget Detail

Excel DocumentProvider Services Cost Summary (Updated 7/16)

Excel DocumentRegion 10 Provider Financial Status Report

PDF DocumentSpecial Projects: Earmarked-Funded Report - Provider  

PDF DocumentSUD Financial Information & Payment Agreement

PDF DocumentSUD Provider Information Sheet

PDF DocumentSUD Services Signature Certification

PDF DocumentSUD Sliding Fee Scale

PDF DocumentWomen's Specialty Services Child Referral Report (Updated 3/17)

PDF DocumentWomen's Specialty Services Report (Updated 12/16) 


 

mix


PDF DocumentComputer Acceptable Use Agreement

PDF DocumentMIX Enrollment (Updated 6/16)


 

other

PDF DocumentAudit Exemption Letter

PDF DocumentConflict of Interest Attestation - Individual

PDF DocumentConflict of Interest Attestation - Provider

Word DocumentConsent / Release of Information  

PDF DocumentContingency Management Quarterly Report

PDF DocumentInvoice

PDF DocumentPrivileging/Credentialing Application - Organization  (Updated 10/17)

Word DocumentPrivileging/Credentialing Application - Practitioner  (Updated 10/17)

PDF DocumentProvider ACH Vendor Authorization

PDF DocumentW-9 Taxpayer ID Number & Certification Request