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. 


02.01.02 Training

PDF DocumentConference Request Form



Data Management


Health Records

03.01.05 Information Systems Security and Protection

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

03.01.09 CareConnect 360 User Guidelines

PDF DocumentRegion 10 PIHP CC360 Annual Usage Report FY22

03.03.03 Behavioral Health Consent Form  

PDF DocumentMDHHS-5515 Consent to Share Behavioral Health Information

PDF DocumentMDHHS-5515-SP Consent to Share Behavioral Health Information (Spanish version)

Health Care


Individual Rights

07.01.03 Sentinel Events Critical Incidents and Risk Events

PDF DocumentRegion 10 Sentinel Event Review Committee Summary Form

PDF DocumentSubstance Use Disorder Program Recipient Rights Complaint Form

Grievances and Appeals 


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


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 2020 Provider Services Cost Summary
*Microsoft Excel version available for Fiscal Year 2020 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


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


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


PDF DocumentInstructions for Monthly Critical Incident Report 
PDF DocumentRegion 10 PIHP - Critical Incident Report
PDF DocumentInstructions for Sentinel Event Summary Form 
PDF DocumentRegion 10 PIHP - Sentinel Event Summary Report                                                                                                  PDF DocumentTreatment Contract Amendment Request Form


PDF DocumentBH TEDS Data Sheet
PDF DocumentTraining Requirements Grid
PDF DocumentMDOC Monthly Progress Report 
PDF DocumentPI SUD Appointment Tracker
*Microsoft Excel version available for PI SUD Appointment Tracker with Instructions