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SUD Providers Required Forms
Provider Forms
Optional Clinical Forms
This page contains a list of forms that are
optional
for contract providers of Genesee County Community Mental Health.
Required Clinical Forms
This page contains a list of forms that are
required
for contract providers of Genesee County Community Mental Health.
Handouts and Administrative
This page contains a list of
handouts and administrative
clinical forms.
SUD Providers Required Forms
A listing of required forms for providers of substance use disorder services.
Required Forms for Substance Use Disorder Service Providers
The following list contains all of the PIHP's required clinical forms for SUD providers.
Title
CA Recipient Rights Complaint
CA Recipient Rights Investigation Report
CA Sliding Fee Scale FY0809
DCH-0385 and 0386 forms
Financial Status Report DCH-0384
Financial Status Report form instructions DCH-0384
IDU 90 Percent Capacity Report
Infectious Disease Screening Instrument
Monthly Monitoring Report - Prevention
Notification of Rights - SA Licensed 10-18-07
Pregnant Woman and Women with Dependent Children Progress Report
Program Budget Summary and Cost Detail Form Instructions DCH 0385 and DCH 0386
Quarterly Narrative Service Report
Release of Information 3-22-10
SUD - Biopsychosocial Assessment 11-21-07
SUD - Biopsychosocial Assessment Update 11-21-07
SUD - Client Questionnaire Adult 11-21-07
SUD - Consent for Medication (NonTD) 11-21-07
SUD - Consent for Release of Confidential Information 11-21-07
SUD - Discharge Summary & Transition Plan 11-21-07
SUD - Drug Court Consent for Release of Information 11-21-07
SUD - Health Screening - Adult 11-21-07
SUD - Health Screening - Child 11-21-07
SUD - Individual Plan of Service 11-21-07
SUD - Medication Review - Updated Plan 11-21-07
SUD - Notice and Hearing Rights - Medicaid 8-16-06
SUD - Notice and Review of Rights - Non-Medicaid 8-7-06
SUD - Physical Health Assessment 8-17-06
SUD - Progress Note 11-21-07
SUD - Psychiatric Evaluation - Plan 11-21-07
Wait List Deficiencies Report
Wait List Deficiencies Report Instructions
Genesee County Community Mental Health
420 W. Fifth Avenue
Flint, MI 48503
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