Region 10 PIHP Forms


substance abuse disorder

PDF DocumentConflict of Interest Attestation - Individual

PDF DocumentConflict of Interest Attestation - Provider

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 Satisfaction Survey  

PDF DocumentPrevention Services Work Plan

Word DocumentPrevention Services Work Plan

Excel DocumentPrevention Quarterly Report

Word DocumentPrevention Staffing Roster

PDF DocumentPrivileging/Credentialing Application - Practitioner (Updated 1/17)

PDF DocumentPrivileging/Credentialing Application - Practitioner Update  

PDF DocumentPrivileging/Credentialing Application - Organization (Updated 8/16)

Excel DocumentProvider Budget Detail

Excel DocumentProvider Services Cost Summary (Updated 7/8/16)

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 DocumentComputer Acceptable Use Agreement

PDF DocumentMIX Enrollment (Updated 6/2016)



PDF DocumentAudit Exemption Letter

Word DocumentConsent / Release of Information  

PDF DocumentContingency Management Quarterly Report

PDF DocumentInvoice

PDF DocumentProvider ACH Vendor Authorization

PDF DocumentW-9 Taxpayer ID Number & Certification Request

PDF DocumentWomen's Specialty Services Child Referral Report (Updated 3/28/17)

PDF DocumentWomen's Specialty Services Report (Updated 12/14/16)