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PROVIDER FORMS
Authorization to Order-Pay Form
Connectivity Request Form
(Citrix/ CMHC connection; New Web-based form)
E-Doc Point of Contact Form
(Web Portal-ONE PER ORGANIZATION)
E-Doc Access Request Form
(Web Portal for STR Completion-ONE PER USER)
Consumer STR Interview and Registration Form
DHHS Incident and Death Report
LME Consumer Admission & Discharge Form
Monthly Attendance Sheet 1-15
Monthly Attendance Sheet 16-31
New Hire / Termination Form
New Hire / Termination Form
(New Web-based form)
Notification of Out of Home Community Placement
Person Centered Plan Forms
Service Auth Request Form
Statistical Change Form
Required Network Provider Criteria Attachment Corporate Application
Required Network Provider Criteria Attachment Form A
Required Network Provider Criteria Attachment Form B
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TDD/Hearing Impaired: 828-325-4698
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