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
• | 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. |
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• | Utilization Management Service Authorization Forms: | ||||||||||||||||||||||||||||||||