Adult Mental Health Division

Provider Forms

Administrative

•	Business Compliance (BC) Report/Referral Form for Suspected Fraud & Abuse (Information on how to report suspected fraud and 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 MS Word)

Performance Improvement

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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 808-453-6939.  In the event of unexpected death of a consumer or other, the provider shall verbally report the event immediately to the Hawaii CARES Line and follow up with a completed Sentinel Event form faxed to the AMHD PI unit by the following day.       • Contact Info       • Immediate Notification Form       • 30-Day Report Form       • Root Cause Analysis Template       • Plan of Improvement (POI) Form       • AMHD MISA Screening Tool: CAGE AID Form (revised May 2011)

Utilization Management

•	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 Form •  8-16 Hour Group Home Service Authorization Request Form •  Semi-Independent Living Service Authorization Request Form •  Bridge Subsidy Authorization Request Form • Bed Hold • Bed Hold Service Authorization Form for 24 Group Home, 8-16 Group Home, TLP and SRSP • Crisis Services • LCRS Continues Stay/Discharge • CSM Dishcarge Service Authorization Form • CMO/CSM Increased units/extension •  Treatment Services • Community-Based Case Management (CBCM) • Certified Peer Specialist • CBCM Increase Units •  Specialized Residential Services (SRSP) •  Clinical Exclusions for SRSP •  Day Treatment Authorization Request Form – Updated form currently unavailable •  Aftercare Authorization Request Form -Updated form currently unavailable •  Therapeutic Living Program (TLP) Service Authorization Request Form – Updated form currently unavailable •  Support Services •  Homeless Outreach • Supported Employment • Increased Units Supportive Employment • Supportive Housing • Increased Units Supportive Housing • Rep Payee Service Authorization Request Form