| Number | Title | Categories | File Type | Link | hf:doc_tags |
|---|---|---|---|---|---|
| 0145 | ABA Consumer Profile | Clinical | |||
0032 | Ability to Pay – Administrative Hearing Disposition | Clinical | |||
0015 | Ability to Pay – Administrative Hearing Findings | Clinical | |||
0028 | Ability to Pay – Administrative Hearing Outcome | Clinical | |||
0006 | Ability to Pay – Administrative Hearing Request | Clinical | |||
0014 | Ability to Pay – Notice of Administrative Hearing | Clinical | |||
0034 | Ability to Pay – Notice of Rights: New Rate Determination, Redetermination, & Appeals | Clinical | |||
0012 | Ability to Pay – Request for Administrative Hearing by Phone | Clinical | |||
0914 | Accident Report – Non-Employee | Safety | |||
0387 | Acknowledgement of Receipt of “Know Your Rights” Booklet | Clinical | |||
0916 | ACT Outcomes Report with Instructions | Clinical | |||
0737 | Administrative Supervision Summary | Supervisory | |||
0164 | Adult Residential Licensing – Resident Assessment for Reimbursement | Clinical | |||
0275 | Advance Beneficiary Notice of Non-coverage (ABN) | Finance | |||
0066 | Alternate Drop-Off Plan | Clinical | |||
1303 | Appeal to Enrollment or Credentialing Denial | Admin | |||
0233 | Application for Training / Endorsement / Certification Reimbursement | Admin | |||
0234 | Application for Tuition Reimbursement | Admin | |||
0807 | Attestation Statement for Population Served | Human Resources | |||
0262 | Auditing Procedures Report – Contracting Agencies other than Residential Services Providers | Finance | |||
0263 | Auditing Procedures Report – Residential Service Providers | Finance | |||
0255 | Authorization Agreement for Automatic Payroll Deposits | Finance | |||
0259 | Authorization Agreement for Electronic Funds Transfers | Finance | |||
0827 | Authorization Consent to Access Michigan MCIR | Human Resources | |||
0250 | Authorization to Disclose Employee Information and Release of Liability | Recipient Rights | |||
MDHHS-1183
| Authorization to Disclose Protected Health Information | MDHHS | |||
0007A | Available Assets | Clinical | |||
0701 | Background Check Notice | Supervisory | |||
0313 | Behavior Treatment Plan Review Committee (BTPRC) Referral | Clinical | docx | ||
0326 | Benefit-2-Work or Work Incentive Practitioner (WIP) Referral | Clinical | |||
0912 | Bloodborne Pathogen Exposure | Safety | |||
0101 | Blue Water Area Transportation Commission Rider Profile | Clinical | |||
0341 | Blue Water Clubhouse Monthly Activity | Clinical | |||
0113 | Buprenorphine Random Count Sheet | Health & Medical | |||
1042 | Buprenorphine Requirement Agreement | Health & Medical | |||
0350 | Camp Attendance Log | Clinical | |||
1034 | Case Consultation | Clinical | |||
MDHHS-1929 | Central Registry Clearance Request | MDHHS | |||
0024 | Certification Order for Professional Assessment | Clinical | |||
0386 | Challenging Behavior Referral | Clinical | |||
0265 | Check Request | Finance | |||
0600 | Childrens Diagnostic and Treatment Specific 24 Training Hours | Training | xlsx | ||
0369 | Clinical Opiate Withdrawl Scale (COWS) | Health & Medical | |||
0735 | Clinical/Direct Service Personnel Supervision | Supervisory | docx | ||
0110 | Clozaril White Blood Count (WBC) & Absolute Neutrophil Count (ANC) History | Health & Medical | |||
1352 | Complaint of Noncompliance | Admin | |||
0201 | Computer / Information Systems Consent | IT & OASIS | |||
0205 | Computer Acceptable Use Agreement | IT & OASIS | |||
0603 | Conference / Training / Workshop Follow-Up Report | Training | |||
0602 | Conference / Training Request | Training | |||
0811 | Confidentiality – Student | Human Resources | |||
0207 | Confidentiality Agreement for Outside Contractors and Other Non-Employees | IT & OASIS | |||
0200 | Confidentiality and Data Security Agreement | IT & OASIS | |||
0016 | Consent – Audio / Visual Authorization | Clinical | |||
0266 | Consent – Casual for a Cause Annual Payroll Deduction | Finance | |||
0381 | Consent – Informed Consent for Blood Draw | Health & Medical | |||
0134 | Consent – Participate in Behavioral Health Telepsychiatry Services | Clinical | |||
0127 | Consent – Participation in Understanding Our Sexuality: Strong, Safe, & Free | Clinical | |||
0362 | Consent – Spravato Treatment | Health & Medical | |||
0353 | Consent – Telephone Authorization Form: Guardian Consent (IPOS, Periodic Review or Amendment) | Clinical | |||
0018 | Consent – Telephone Authorization: Guardian Consent | Clinical | |||
0150 | Consent for Exercise Program | Health & Medical | |||
0338 | Consent for Observation | Clinical | |||
MDHHS-5515 | Consent to Share Behavioral Health Information For Care Coordination Purposes | MDHHS | |||
1307 | Consent – Out of County Travel CIS | Clinical | |||
0287 | Contract Provider Compliance Complaints – Quarterly Report | Admin | |||
0112 | Controlled Substance Count Sheet | Health & Medical | |||
0267 | Cost Calculation – Contract Provider Multiple Rates | Finance | xlsx | ||
0268 | Cost Calculation – Contract Provider Single Rate | Finance | |||
0269 | Cost Calculation – Residential SLA | Finance | xlsx | ||
0251 | Credit Card Charge Log | Finance | |||
0248 | Credit Card – Cardholder Agreement | Finance | |||
0249 | Credit Card – Receipt Exception | Finance | |||
0009 | Credit/Debit Card Pre-Authorization | Clinical | |||
0126 | Crisis Alert/Diversion Recommendations for McLaren | Clinical | docx | ||
0130 | Crisis Group Home Determination | Clinical | |||
1047 | Crisis Safety Plan | Clinical | |||
MDHHS-3803 | Data Sheet and Prescription For Personal Care – Recipients in Alternative Residential Settings | MDHHS | |||
0700 | Direct Service Activity Review | Supervisory | |||
0799 | Disclosure of Personal Involvement | Human Resources | |||
0801 | Driving Record Check | Human Resources | |||
0732 | Drug Testing – Consent to Diagnostic Procedure & Release of Information Authorization | Supervisory | |||
0731 | Drug Testing – Employee Certification of Notification | Supervisory | |||
0252 | Emergency Check Request | Finance | |||
0910 | Emergency Event | Safety | |||
0802 | Employee Accident Report | Human Resources | |||
0702 | Employee Communication Memo | Supervisory | |||
0703 | Employee Discipline Report | Supervisory | |||
0812 | Employee Request for Transfer Memo | Human Resources | |||
0707 | Employee Termination – Sample Letter of Resignation or Quit Acceptance | Supervisory | |||
0705 | Employee Termination Property Receipt Record | Supervisory | |||
0706 | Employee Termination Sample Letter of Release During Probation or Temporary Employment | Supervisory | |||
0819 | Employee Training Worksheet | Human Resources | |||
0714 | Employment Reference Consent | Supervisory | |||
0831 | Employment Reference Release | Human Resources | |||
0335 | Employment Services (IPS) – Fidelity Supervision | Clinical | |||
0324 | Employment Services (IPS) – Follow Along Supports Plan | Clinical | docx | ||
0331 | Employment Services (IPS) – Job Target | Clinical | |||
0323 | Employment Services (IPS) – Orientation | Clinical | docx | ||
0330 | Employment Services (IPS) – Vocational Profile Update | Clinical | docx | ||
0226 | Facility Use Request | Admin | |||
0003A | Financial Information and Payment Agreement (Specialized Group Homes/Foster Homes, Inpatient >60 Days) | Clinical | |||
0911 | Fire Drill Log and Evaluation | Safety | |||
0230B | FOIA – Appeal Form – Appeal of Denial | Admin | |||
0230C | FOIA – Appeal Form – Excess Fee | Admin | |||
0230A | FOIA – Detailed Cost Itemization | Admin | |||
0229 | FOIA – Request for Disclosure of Public Records | Admin | |||
0230 | FOIA – Response to Request for Public Records | Admin | |||
MDHHS-5926 | Habilitation Supports Waiver (HSW) – Application Worksheet | MDHHS | |||
MDHHS-3894 | Habilitation Supports Waiver (HSW) – Eligibility Certification | MDHHS | |||
MDHHS-5927 | Habilitation Supports Waiver (HSW) – Performance on Major Life Activity | MDHHS | |||
0828 | Harassment Complaint | Human Resources | |||
HCBS-NR | HCBS Non-Residential Provider Application | Other | docx | ||
HCBS-R | HCBS Residential Provider Application | Other | docx | ||
0055 | Health Care Chronological | Health & Medical | |||
0730 | Henry Ford Employer Solutions: Employer Authorization for Treatment/Billing | Supervisory | |||
0805 | Hepatitis B Vaccine Consent / Waiver | Human Resources | |||
0114A | Housing Fund – Intake | Clinical | |||
0114 | Housing Fund – Memorandum | Clinical | |||
0913 | Incident of Weapons and/or Drugs in the Workplace | Safety | |||
0057 | Incident Report | Clinical | |||
0146 | Individual Plan of Service (IPOS) Training Log | Clinical | |||
0316 | Individual Profile | Clinical | |||
0725 | Industrial Health – Medical Authorization | Supervisory | |||
0160 | InSHAPE – Orientation | Health & Medical | |||
0163 | InShape, Bfit, Health Matters – Self Health Action Plan for Empowerment | Health & Medical | |||
0161 | InShape, Bfit, Health Matters Referral | Health & Medical | |||
0162 | InShape, Bfit, Health Matters- Medical Clearance | Health & Medical | |||
0002A | Installment Payment Agreement – Hospital Inpatient | Clinical | |||
0004 | Installment Payment Agreement – Outpatient | Clinical | |||
0002 | Installment Payment Agreement – Specialized Residential | Clinical | |||
0236 | Instructor Confidentiality Agreement | Admin | |||
0392 | Intensive Care Coordination w/ Wraparound (ICCW) – Crisis/Safety Plan | Clinical | |||
0339 | Intensive Care Coordination w/ Wraparound (ICCW) – Graduation Summary | Clinical | |||
0394 | Intensive Care Coordination w/ Wraparound (ICCW) – Initial Plan | Clinical | |||
0397 | Intensive Care Coordination w/ Wraparound (ICCW) – Needs Assessment | Clinical | |||
0399 | Intensive Care Coordination w/ Wraparound (ICCW) – Team Members | Clinical | |||
0337 | Intensive Care Coordination w/ Wraparound (ICCW) – Transition Plan | Clinical | |||
1304 | Level 1 Authorization Training Attestation | Admin | |||
0280 | Location Maintenance | IT & OASIS | |||
0073 | Maintenance / Repair Request | Safety | |||
0121 | Medicaid Deductible Worksheet | Clinical | |||
0050 | Medical Appointment Information Record | Health & Medical | |||
0231 | Medical Records – Records Request Inquiry | Admin | |||
0059 | Medical Release of Information – Consent for Hepatitis B / HIV Blood Testiing (This Form is for SUD Use Only) | Health & Medical | |||
0384 | Medication – Delivery | Health & Medical | |||
0305 | Medication – Disposal | Health & Medical | |||
0311 | Medication – Genoa Refill Request | Health & Medical | |||
0048 | Medication Administration Record | Health & Medical | |||
0049 | Medication Counts | Health & Medical | |||
0049A | Medication Counts – Day Programs | Health & Medical | |||
0051 | Medication Error Report | Health & Medical | |||
0008 | Medication Transfer | Health & Medical | |||
0340 | Mental Health Services Emergency Pre-Admission Screening | Clinical | |||
0388 | Mental Health Treatment Order – Non-Compliance Pick-Up Order | Clinical | |||
0841 | Mentoring Program – Mentee Application | Human Resources | |||
0843 | Mentoring Program – Mentee Progress Note | Human Resources | |||
0840 | Mentoring Program – Mentor Application | Human Resources | |||
0842 | Mentoring Program – Mentorship Agreement and Personal Development Plan | Human Resources | |||
0206 | Mobile Device Letter of Agreement | IT & OASIS | |||
0370 | No Identification or Decline to Provide Identification | Clinical | |||
0115 | Non-Crisis Group Home Agency Profile | Clinical | |||
1039 | Notice of Disclaimer | Clinical | |||
0733 | Notification of Employee Performance Review | Supervisory | |||
0286 | OASIS Refresher Training | IT & OASIS | |||
0334 | Objective Opiate Withdrawl Scale (OOWS) | Health & Medical | |||
0253 | On Call Timesheet | Finance | xlsx | ||
0601 | Opportunity for Improvement Plan | Supervisory | docx | ||
1301 | Organization Application | Admin | |||
1302 | Organizational Deemed Status Request | Admin | |||
0254 | Overnight Per Diem Worksheet | Finance | |||
0806 | Overtime Documentation | Human Resources | |||
0120 | Parent(S) Financial Determination for Minor Children (Less Than 18yrs.) Receiving Specialized Residential Services | Clinical | |||
0274 | Patient Responsibility Agreement | Finance | |||
0274 | Patient Responsibility Agreement (Spanish) | Finance | |||
0124 | Periodic Review Sheet for BTPRC Behavior Plans | Clinical | docx | ||
0826 | Personal Use of Any Cell Phone During Paid Working Hours | Human Resources | |||
0830 | Personnel Change of Information | Human Resources | |||
0261 | Petty Cash Request | Finance | |||
0179 | Physician Referral for Dietitian | Health & Medical | |||
0154 | Port of Hopes Inc.: Drop-In Center Eligibility Verification | Clinical | |||
0125 | Positive Behavior Supports Survey | Clinical | |||
1300 | Practitioner Application Network Enrollment and Credentialing | Admin | |||
0736 | Pre-Employment Notification and Acknowledgement | Human Resources | |||
0225 | Prescriber Case Consultation Request | Admin | |||
0222 | Prescriber Peer Review | Admin | |||
1023 | Prescription for OT/PT Professional Assessments | Health & Medical | |||
0228 | Program Performance Indicator (PI) Plan of Correction | Admin | |||
0041 | Program Placement / Transfer Meeting | Clinical | |||
0041C | Program Placement / Transfer Meeting – Transfer Checklist (Optional) | Clinical | |||
0726 | Program Supervisory Plan Outline | Supervisory | |||
0221 | Provider Enrollment Information and Consent | Admin | |||
0281 | Provider Enrollment – Update or Disenrollment for OASIS | IT & OASIS | |||
0256 | Purchase Order | Finance | xlsx | ||
0285 | Quality Improvement Plan (QIP) | Clinical | |||
0740 | Reasonable Suspicion Determination Report | Human Resources | |||
MDHHS-0030 | Recipient Rights Complaint | MDHHS | |||
KIDS | Referral – Kids in Distress Services, Inc. | Other | |||
0144 | Referral – Suboxone | Health & Medical | |||
SAL-0001 | Referral for the Salvation Army Social Service Department | Other | |||
MDHHS-3471 | Referral Form – DHS/ SSA | MDHHS | |||
0327 | Referral – Employment Services (IPS) | Clinical | |||
0354 | Referral – Intensive Care Coordination w/ Wraparound (ICCW) | Clinical | |||
1306 | Region 10 Conflict of Interest Attestation – Entity Provider | Admin | |||
1305 | Region 10 Conflict of Interest Attestation – Individual Provider | Admin | |||
0373 | Release – Actor | Clinical | |||
0374 | Release – Artwork | Clinical | |||
0380 | Release – Authorization for Release of Information for Staff Testimony | Clinical | |||
0382 | Release – Newsletters, Annual Reports, Public Relations, and Related Uses | Clinical | |||
0375 | Release – Video/Photograph | Clinical | |||
0376 | Release – Writing | Clinical | |||
MDHHS-3200 | Report of Actual or Suspected Child Abuse or Neglect | MDHHS | |||
0007 | Request for a New Rate Determination | Clinical | |||
0715 | Request for a Temporary Assignment or Temporary Employment | Supervisory | |||
0917 | Request for Amendment of Protected Health Information | Clinical | |||
0815 | Request for Leave of Absence | Human Resources | |||
0282 | Request for New Location Code | IT & OASIS | |||
0232 | Request for Policy / Administrative Procedure Exception | Admin | |||
0031 | Request for Transfer to an Alternate Prescriber | Clinical | |||
0825 | Request for Tuition/Training/Endorsement/Certification Reimbursement | Human Resources | |||
0223 | Request to Create New Group | Admin | |||
0264 | Request to Send Responsible Party to the Credit Bureau or Write-Off Account | Finance | |||
0271 | Request to Waive Assessed Ability to Pay or Fee Per Session | Finance | |||
BCAL-2319 | Resident Funds | Other | |||
0832 | Return to Work Commitment – Paid Parental Leave | Human Resources | |||
1021 | Review of OT/PT Services (Medicare only) | Health & Medical | |||
1038 | Safety In-Home Training Checklist | Clinical | |||
0734 | Sample Letter of Completion of Probationary Period | Supervisory | |||
0224 | SCCCMH Conflict of Interest Disclosure | Admin | |||
0047B | Seizure – Historical Seizure Report | Health & Medical | |||
0047 | Seizure – Report of Seizure | Health & Medical | |||
0306 | Self-Administration of Medication (SAM) Assessment Tool | Health & Medical | |||
0307 | Self-Administration of Medication (SAM) Weekly Log | Health & Medical | |||
0123 | Sentinel Event Root Cause Analysis (RCA) | Clinical | docx | ||
0276 | Sliding Fee Discount Program Handbook | Finance | |||
0070 | SOAR Referral | Clinical | |||
0247 | Special Committee/Advisory Council Member Voucher | Finance | |||
0025C | Special Consent Behavior Treatment Intervention | Clinical | |||
0257 | Special Fund Account Request | Finance | |||
0117 | Specialized Group/Foster Homes or Inpt >60 days – Earned Income Worksheet | Clinical | |||
0118 | Specialized Group/Foster Homes or Inpt >60 days – Fee Determination for Mental Health Services | Clinical | |||
0116 | Specialized Group/Foster Homes or Inpt >60 days – Financial Ability to Pay Agreement: Summary & Signature Page | Clinical | |||
0119 | Specialized Group/Foster Homes or Inpt >60 days – Full Financial Review Income/Expenses Analysis | Clinical | |||
1024A | Specialized Residential Personal Care and Community Living Supports Log | Clinical | |||
0091 | Specialized/Enhanced Medical Equipment and Supplies, Environmental Modifications and/or Enhanced Pharmacy | Clinical | |||
0359 | Spravato – Hamilton Depressing Rating Scale (HAM-D) | Health & Medical | |||
0360 | Spravato – Questionnaire Regarding History of Dissociation | Health & Medical | |||
0361 | Spravato – Screening Questions | Health & Medical | |||
0258 | Staff Credit Card Request | Finance | |||
0728 | Staff Meeting Training | Supervisory | |||
0383 | Staff Task Tracker | Admin | |||
1400 | Staff Training Request | Training | |||
0029A | Standing Medication Order | Health & Medical | |||
0029B | Standing Medication Order – List for Children Ages 2 through 11 Years of Age | Health & Medical | |||
0029C | Standing Medication Order – List for Individuals 12 Years of Age and Older | Health & Medical | |||
0029 | Standing Medication Order – Missed | Health & Medical | |||
SSA-1945 | Statement Concerning Your Employment in a Job Not Covered by Social Security | SSA | |||
0824 | Student / Volunteer – Information/Authorization | Human Resources | |||
0820 | Student / Volunteer Data Sheet | Human Resources | |||
0821 | Student Evaluation | Human Resources | |||
0823 | Student Placement Proposal | Human Resources | |||
0345 | Student Pre-Screen Disposition | Clinical | |||
0822 | Student Request for Placement | Human Resources | |||
0333 | Subjective Opiate Withdrawl Scale (SOWS) | Health & Medical | |||
LARA-210 | Substance Use Disorder Programs – Complainants Appeal to the Regional Entity Rights Consultant | LARA | |||
LARA-225 | Substance Use Disorder Programs – Departments Investigation Report | LARA | |||
LARA-205 | Substance Use Disorder Programs – Program Rights Advisors Investigation Report | LARA | |||
LARA-220 | Substance Use Disorder Programs – Recipient Rights Appeal to the Department | LARA | |||
LARA-200 | Substance Use Disorder Programs – Recipient Rights Complaint Form | LARA | |||
LARA-215 | Substance Use Disorder Programs – Regional Entity Rights Consultant Investigation Report | LARA | |||
0378 | Substance Use Disorder Services Program: Attestation Statement/Policy Review | Human Resources | |||
0067 | Summary Report for Guardianship | Clinical | |||
0729 | Supervisor Feedback | Supervisory | |||
FTOC | Table of Contents: Forms | Table of Contents | |||
TOC | Table of Contents: Policies | Table of Contents | |||
0723 | Telephone Reference Check | Supervisory | |||
0260 | Travel/Expense Voucher | Finance | xlsx | ||
0068 | Treatment Agreement | Clinical | |||
0332 | Urine Drug Screen Result Record | Health & Medical | |||
0238 | Utilization Management Affirmation Statement About Incentives | Admin | |||
1044 | Utilization Review Reconsideration and Disposition | Clinical | |||
0813 | Vacation Cap Variance Request | Human Resources | |||
0804 | Variable Work Schedule | Human Resources | |||
0343 | Waiver – Choking Incident | Health & Medical | |||
0348 | Waiver – Trauma-Informed Yoga Liability Waiver & Release | Health & Medical | |||
0833 | Worker’s Compensation Disclaimer for Interns | Human Resources | |||
0814 | Working Remotely Packet | Human Resources | |||
0178 | Wraparound Request for Services- GAP Pool Funds | Clinical | |||
0318 | Youth Peer Support Specialist (YPSS) Consumer Profile | Clinical |