Forms commonly used by the twenty-four Local Health Departments |
| Schedule of Charges - DHMH 4411 A & B |
LHDSochargeA.doc
LHDSochargeA.pdf |
| FY 13 Non-Chargeable List |
FY13-NonChargeableList
FY13-NonChargeableList |
| FY 13 Out Patient Services - Ability to Pay Scale |
AbilitytoPayScheduleFY13OutpatientServices
AbilitytoPayScheduleFY13OutpatientServices |
| ADAA Halfway House, Long Term Care & Residential ICF - Ability to Pay Scale |
ADAA-AbilitytoPayScheduleFY13
ADAA-AbilitytoPayScheduleFY13 |
| FY 13 Adult Day Care Services - Ability to Pay Scale |
ADC-AbilitytoPayScheduleFY13
ADC-AbilitytoPayScheduleFY13 |
| MHA Residential Program Fee Determination (effective 7/1/05) |
feeform.pdf |
| Worksheet to be used for Halfway House, Long Term Care & Residential ICF |
FY13-ADAA-ATPS-Instructions-Revised-6-11.doc
FY13-ADAA-ATPS-Instructions-Revised-6-11.pdf |
| Instructions for completing the MH Residential Fee Form |
MHFeeDeterminationInst.doc
MHfeeDeterminationInst.pdf |
| |
Forms commonly used by the Private Vendors: |
| Schedule of Charges - DHMH 4411 A & B |
ADAA4411aschedule.doc
ADAA4411aschedule.pdf ADAA4411bschedule.xls
ADAA4411bschedule.pdf
ADAAdefinition4411b.doc
ADAAdefinition4411b.pdf |
| FY 13 Non-Chargeable List |
FY13-NonChargeableList
FY13-NonChargeableList |
| FY 13 Out Patient Services - Ability to Pay Scale |
AbilitytoPayScheduleFY13OutpatientServices
AbilitytoPayScheduleFY13OutpatientServices |
| ADAA Halfway House, Long Term Care & Residential ICF - Ability to Pay Scale |
ADAA-AbilitytoPayScheduleFY13.xls
ADAA-AbilitytoPayScheduleFY13.pdf |
| FY 13 Adult Day Care Services - Ability to Pay Scale |
ADC-AbilitytoPayScheduleFY13
ADC-AbilitytoPayScheduleFY13 |
| MHA Residential Program Fee Determination (effective 7/1/05) |
feeform.pdf |
| Worksheet to be used for Halfway House, Long Term Care & Residential ICF |
FY13-ADAA-ATPS-Instructions-Revised-6-11.doc
FY13-ADAA-ATPS-Instructions-Revised-6-11.pdf |
| Instructions for completing the MH Residential Fee Form |
MHFeeDeterminationInst.doc
MHfeeDeterminationInst.pdf |
| |
Forms Commonly used by the Fee Payment System Vendors |
| Fee Payment System Invoice - DHMH 4356 |
fpysyinv.doc
fpysyinv.pdf |
| Fee Payment System Invoice - DHMH 4513 |
dhmh_4513.doc
dhmh_4513.pdf |