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
Governance
01.01.01 Region 10 PIHP Board
PIHP Board Member Application FormPIHP Board Member Interview FormBoard Profile Report
01.01.02 Board Member Per Diem and Travel Reimbursement
Expense Voucher FormConference Request FormWaiver of Per Diem FormWaiver of Travel Reimbursement Form
01.01.03 Substance Use Disorder Oversight Policy Board
Expense Voucher FormRegion 10 SUD Policy Oversight Board Waiver of Per DiemRegion 10 SUD Policy Oversight Board Waiver of TravelRegion 10 SUD Policy Oversight Board Member ProfileConference Request Form
Compliance
01.02.04 Freedom of Information Act Requests
FOIA Request for Disclosure of Public RecordsResponse to Request for Public Records – FOIA
01.02.06 Disclosure of Information
Conflict of Interest Attestation Form- ProviderConflict of Interest Attestation Form – Individual
General Operations
Quality Management
01.04.04 Behavior Management Review
Utilization Management
None
Provider Network
01.06.05 Credentialing & Privileging
Privileging & Credentialing Application - OrganizationPrivileging & Credentialing Organization Additional SUD Location FormPrivileging & Credentialing Organization Additional CMH Location FormPrivileging & Credentialing Application - Practitioner
Chapter 2: Human Resources Policy Forms
Chapter 3: Information Management Policy Forms
Technology
None
Data Management
None
Health Records
03.01.05 Information Systems Security and Protection
Region 10 PIHP Computer Acceptable Use Agreement MIX Software Enrollment Request Form
03.01.09 CareConnect 360 User Guidelines
Region 10 PIHP CC360 Annual Usage Report FY22
03.03.03 Behavioral Health Consent Form
MDHHS-5515 Consent to Share Behavioral Health Information
MDHHS-5515-SP Consent to Share Behavioral Health Information (Spanish version)
Chapter 4: Fiscal Management Policy Forms
Budget
None
Accounting
04.02.03 Credit Card Usage
Receipt Exception Form
Cardholder Agreement
04.02.04 Ability to Pay for SUD Services
Substance Use Disorder Financial Information and Payment Agreement/SUD Sliding Fee Scale
Substance Use Disorder Notice of Rights for Ability to Pay
Substance Use Disorder Request for a New Rate Determination
Substance Use Disorder New Determination
Substance Use Disorder Request to Reduce or Waive Assessed Fee
Substance Use Disorder Ability to Pay Administrative Hearing Request
Substance Use Disorder Request for Ability to Pay Administrative Hearing by Telephone
Substance Use Disorder Ability to Pay Administrative Hearing Notice
Substance Use Disorder Ability to Pay Administrative Hearing Disposition Form
Substance Use Disorder Notice of Outcome of Ability to Pay Administrative Hearing
Determination of Taxable Income
Guidelines of Inclusion & Exclusion of Assets, Income and Expenses
Reimbursement
None
Chapter 5: Clinical Practice Guidelines Policy Forms
Access to Services
None
Customer Services
None
Care Delivery
05.03.02 Habilitation Supports Waiver
MDHHS Habilitation Supports Waiver Certification
MDHHS HSW Major Life Activity Form
MDHHS HSW New Applicant and Recertification Worksheet
05.03.09 Naloxone
Naloxone Monthly Report
Naloxone Registration Form - General
Naloxone Registration Form - Law Enforcement
Naloxone Registration Form - SCCHD
Naloxone Registration Form - Wellness
Naloxone Use Form
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
Region 10 Sentinel Event Review Committee Summary Form
Substance Use Disorder Program Recipient Rights Complaint 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
Ability to Pay Administrative Hearing by Telephone
Ability to Pay Administrative Hearing Disposition FormAbility to Pay Administrative Hearing NoticeAbility to Pay Administrative Hearing RequestAudit Exemption LetterDetermination of Taxable IncomeFinancial Information & Payment Agreement/Sliding Fee ScaleFiscal Year 2020 Provider Services Cost Summary
*Microsoft Excel version available for Fiscal Year 2020 Provider Services Cost Summary. Fiscal Year 2018 Unbilled SUD Services
*Microsoft Excel version available for Fiscal Year 2018 Unbilled SUD Services. Guidelines for Inclusion & Exclusion of Assets, Income and ExpensesNew DeterminationNotice of Outcome of Ability to Pay Administrative HearingNotice of Rights for Ability to PayProvider ACH Vendor AuthorizationProvider Budget Detail
*Microsoft Excel version available for Provider Budget Detail.Region 10 Provider Financial Status Report
*Microsoft Excel version available for Region 10 Provider Financial Status Report.Request for a New Rate DeterminationRequest to Reduce or Waive Assessed FeeW-9 Request for Taxpayer Identification Number and Certification
Naloxone
Naloxone Monthly ReportNaloxone Registration Form - GeneralNaloxone Registration Form - Law EnforcementNaloxone Registration Form - Wellness Overdose Prevention & Naloxone Use Report
Prevention
Prevention Contract Amendment ProposalPrevention Program Fee ReportPrevention Providers Staffing Roster Prevention Satisfaction Survey Prevention Services Outcome Evaluation ReportPrevention Services Work Plan
TREATMENT
Instructions for Monthly Critical Incident Report Region 10 PIHP - Critical Incident ReportInstructions for Sentinel Event Summary FormRegion 10 PIHP - Sentinel Event Summary Report
Treatment Contract Amendment Request Form
Other
BH TEDS Data SheetTraining Requirements GridMDOC Monthly Progress Report PI SUD Appointment Tracker
PI SUD Appointment Tracker (Excel format)