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Local Health Departments and Private Vendors

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