Provider Forms

Administrative

•  Business Compliance (BC) Report/Referral Form for Suspected Fraud & Abuse
•  Consumer Update Form
•  Provider Contact Change Form
•  Provider Claim & Payment Inquiry Form
•  Provider Quarterly Self Report
•  Provider Service Authorization Inquiry Form

Clinical

•  Application for Emergency Examination and Treatment (MH-2 Application)
•  Reporting a Sentinel Event
Providers are required to report sentinel events, as defined in AMHD policy “Sentinel Events”.  AMHD providers are required to report all consumer sentinel events to the AMHD Performance Improvement (PI) unit by the next working day by faxing the completed Sentinel Event form to 808-453-6995.  In the event of unexpected death of a consumer or other, the provider shall verbally report the event immediately to the AMHD ACCESS Line and follow up with a completed Sentinel Event form faxed to the AMHD PI unit by the following day.
      • Contact Info
      • Consumer Immediate Notification
      • 30-day report
      • Root Cause Analysis Template
      • Plan of Improvement (POI) Form
      • AMHD MISA Screening Tool: CAGE AID Form (revised May 2011)

Utilization Management

•  UM Additional CBCM Service Units Authorization Request Form
•  DOH AMHD Universal Referral Form: The DOH AMHD Universal Referral
Form is to be used for all referrals to the AMHD service array.
 
•  Universal Referral Form Attachment A: Covers the following:

•  Community Based Case Management (CBCM)
•  Day Treatment, Intensive Out Patient Hospital (IOH)
•  Expanded Adult Residential Care Home (E-ARCH)
•  Hale Imua
•  KFit
•  Specialized Residential Services Program (SRSP)
•  Therapeutic Living Program (TLP)
•  Universal Referral Form Attachment B: Representative Payee Services
•  Universal Referral Form Attachment C: Covers the following:

•  24 Hour Group Home
•  8-16 Hour Group Home
•  Semi-Independent Living
•  Supported Housing    
  Shelter Plus Care
•  Universal Referral Form Attachment D: Additional information required
by all federally funded housing
•  Utilization Management Service Authorization Forms:
 
•  Housing Services

•  24 Hour Group Home Service Authorization Request Forms
•  8-16 Hour Group Home Service Authorization Request Forms
•  Semi-Independent Living Service Authorization Request Forms
•  Supported Housing Service Authorization Request Forms
 
•  Treatment Services

•  Specialized Residential (SRSP) Service Authorization Request Form
•  Clinical Exculsions for SRSP
•  Day Treatment Authorization Request Form
•  Aftercare Authorization Request Form
•  Therapeutic Living Program (TLP) Service Authorization Request Form
 
•  Support Services

•  Rep Payee Service Authorization Request Form
Supported Employment Service Authorization Request Form

Milestone 1: Job Placement three (3) days
Milestone 2: thirty (30) Day Job Retention
Milestone 3: ninety (90) Day Job Retention
Milestone 4: one hundred eighty (180) Day Job Retention
Milestone 5: three hundred sixty (360) Day Job Retention