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NumberTitleCategoriesFile TypeLinkhf:doc_tagshf:doc_categories
0145ABA Consumer ProfileClinicalpdfclinical

0032

Ability to Pay – Administrative Hearing DispositionClinicalpdfclinical

0015

Ability to Pay – Administrative Hearing FindingsClinicalpdfclinical

0028

Ability to Pay – Administrative Hearing OutcomeClinicalpdfclinical

0006

Ability to Pay – Administrative Hearing RequestClinicalpdfclinical

0014

Ability to Pay – Notice of Administrative HearingClinicalpdfclinical

0034

Ability to Pay – Notice of Rights: New Rate Determination, Redetermination, & AppealsClinicalpdfclinical

0012

Ability to Pay – Request for Administrative Hearing by PhoneClinicalpdfclinical

0914

Accident Report – Non-EmployeeSafetypdfsafety

0387

Acknowledgement of Receipt of “Know Your Rights” BookletClinicalpdfclinical

0916

ACT Outcomes Report with InstructionsClinicalpdfclinical

0836

ADA Accommodation ChecklistHuman Resourcespdfhuman-resources

0835

ADA Medical Certification FormHuman Resourcespdfhuman-resources

0834

ADA Reasonable Accommodation Request FormHuman Resourcespdfhuman-resources

0737

Administrative Supervision SummarySupervisorypdfsupervisory

0164

Adult Residential Licensing – Resident Assessment for ReimbursementClinicalpdfclinical

0275

Advance Beneficiary Notice of Non-coverage (ABN)Financepdffinance

1303

Appeal to Enrollment or Credentialing DenialAdminpdfadmin

0233

Application for Training / Endorsement / Certification ReimbursementAdminpdfadmin

0234

Application for Tuition ReimbursementAdminpdfadmin

0807

Attestation Statement for Population ServedHuman Resourcespdfhuman-resources

0262

Auditing Procedures Report – Contracting Agencies other than Residential Services ProvidersFinancepdffinance

0263

Auditing Procedures Report – Residential Service ProvidersFinancepdffinance

0255

Authorization Agreement for Automatic Payroll DepositsFinancepdffinance

0259

Authorization Agreement for Electronic Funds TransfersFinancepdffinance

0827

Authorization Consent to Access Michigan MCIRHuman Resourcespdfhuman-resources

0250

Authorization to Disclose Employee Information and Release of LiabilityRecipient Rightspdfrecipient-rights

MDHHS-1183

 

Authorization to Disclose Protected Health InformationMDHHSpdfmdhhs

0007A

Available AssetsClinicalpdfclinical

0701

Background Check NoticeSupervisorypdfsupervisory

0313

Behavior Treatment Plan Review Committee (BTPRC) ReferralClinicaldocxclinical

0326

Benefit-2-Work or Work Incentive Practitioner (WIP) ReferralClinicalpdfclinical

0912

Bloodborne Pathogen ExposureSafetypdfsafety

0341

Blue Water Clubhouse Monthly ActivityClinicalpdfclinical

0113

Buprenorphine Random Count SheetHealth & Medicalpdfhealth-medical

1042

Buprenorphine Requirement AgreementHealth & Medicalpdfhealth-medical

0350

Camp Attendance LogClinicalpdfclinical

1034

Case ConsultationClinicalpdfclinical

MDHHS-1929

Central Registry Clearance RequestMDHHSpdfmdhhs

0024

Certification Order for Professional AssessmentClinicalpdfclinical

0386

Challenging Behavior ReferralClinicalpdfclinical

0265

Check RequestFinancepdffinance

0600

Childrens Diagnostic and Treatment Specific 24 Training HoursTrainingxlsxtraining

0369

Clinical Opiate Withdrawl Scale (COWS)Health & Medicalpdfhealth-medical

0735

Clinical/Direct Service Personnel SupervisionSupervisorydocxsupervisory

0110

Clozaril White Blood Count (WBC) & Absolute Neutrophil Count (ANC) HistoryHealth & Medicalpdfhealth-medical

1352

Complaint of NoncomplianceAdminpdfadmin

0201

Computer / Information Systems ConsentIT & OASISpdfit-oasis

0205

Computer Acceptable Use AgreementIT & OASISpdfit-oasis

0603

Conference / Training / Workshop Follow-Up ReportTrainingpdftraining

0602

Conference / Training RequestTrainingpdftraining

0811

Confidentiality – StudentHuman Resourcespdfhuman-resources

0207

Confidentiality Agreement for Outside Contractors and Other Non-EmployeesIT & OASISpdfit-oasis

0200

Confidentiality and Data Security AgreementIT & OASISpdfit-oasis

0016

Consent – Audio / Visual AuthorizationClinicalpdfclinical

0266

Consent – Casual for a Cause Annual Payroll DeductionFinancepdffinance

0381

Consent – Informed Consent for Blood DrawHealth & Medicalpdfhealth-medical

0134

Consent – Participate in Behavioral Health Telepsychiatry ServicesClinicalpdfclinical

0127

Consent – Participation in Understanding Our Sexuality: Strong, Safe, & FreeClinicalpdfclinical

0362

Consent – Spravato TreatmentHealth & Medicalpdfhealth-medical

0353

Consent – Telephone Authorization Form: Guardian Consent (IPOS, Periodic Review or Amendment)Clinicalpdfclinical

0018

Consent – Telephone Authorization: Guardian ConsentClinicalpdfclinical

0150

Consent for Exercise ProgramHealth & Medicalpdfhealth-medical

0338

Consent for ObservationClinicalpdfclinical

MDHHS-5515

Consent to Share Behavioral Health Information For Care Coordination PurposesMDHHSpdfmdhhs

1307

Consent – Out of County Travel CISClinicalpdfclinical

0287

Contract Provider Compliance Complaints – Quarterly ReportAdminpdfadmin

0112

Controlled Substance Count SheetHealth & Medicalpdfhealth-medical

0267

Cost Calculation – Contract Provider Multiple RatesFinancexlsxfinance

0268

Cost Calculation – Contract Provider Single RateFinancepdffinance

0269

Cost Calculation – Residential SLAFinancexlsxfinance

0251

Credit Card Charge LogFinancepdffinance

0248

Credit Card – Cardholder AgreementFinancepdffinance

0249

Credit Card – Receipt ExceptionFinancepdffinance

0009

Credit/Debit Card Pre-AuthorizationClinicalpdfclinical

0126

Crisis Alert/Diversion Recommendations for McLarenClinicaldocxclinical

0130

Crisis Group Home DeterminationClinicalpdfclinical

1047

Crisis Safety PlanClinicalpdfclinical

MDHHS-3803

Data Sheet and Prescription For Personal Care – Recipients in Alternative Residential SettingsMDHHSpdfmdhhs

0700

Direct Service Activity ReviewSupervisorypdfsupervisory

0799

Disclosure of Personal InvolvementHuman Resourcespdfhuman-resources

0801

Driving Record CheckHuman Resourcespdfhuman-resources

0732

Drug Testing – Consent to Diagnostic Procedure & Release of Information AuthorizationSupervisorypdfsupervisory

0731

Drug Testing – Employee Certification of NotificationSupervisorypdfsupervisory

0252

Emergency Check RequestFinancepdffinance

0910

Emergency EventSafetypdfsafety

0802

Employee Accident ReportHuman Resourcespdfhuman-resources

0702

Employee Communication MemoSupervisorypdfsupervisory

0703

Employee Discipline ReportSupervisorypdfsupervisory

0812

Employee Request for Transfer MemoHuman Resourcespdfhuman-resources

0707

Employee Termination – Sample Letter of Resignation or Quit AcceptanceSupervisorypdfsupervisory

0705

Employee Termination Property Receipt RecordSupervisorypdfsupervisory

0706

Employee Termination Sample Letter of Release During Probation or Temporary EmploymentSupervisorypdfsupervisory

0819

Employee Training WorksheetHuman Resourcespdfhuman-resources

0714

Employment Reference ConsentSupervisorypdfsupervisory

0831

Employment Reference ReleaseHuman Resourcespdfhuman-resources

0335

Employment Services (IPS) – Fidelity SupervisionClinicalpdfclinical

0324

Employment Services (IPS) – Follow Along Supports PlanClinicaldocxclinical

0331

Employment Services (IPS) – Job TargetClinicalpdfclinical

0323

Employment Services (IPS) – OrientationClinicaldocxclinical

0330

Employment Services (IPS) – Vocational Profile UpdateClinicaldocxclinical

0226

Facility Use RequestAdminpdfadmin

0003A

Financial Information and Payment Agreement (Specialized Group Homes/Foster Homes, Inpatient >60 Days)Clinicalpdfclinical

0911

Fire Drill Log and EvaluationSafetypdfsafety

0230B

FOIA – Appeal Form – Appeal of DenialAdminpdfadmin

0230C

FOIA – Appeal Form – Excess FeeAdminpdfadmin

0230A

FOIA – Detailed Cost ItemizationAdminpdfadmin

0229

FOIA – Request for Disclosure of Public RecordsAdminpdfadmin

0230

FOIA – Response to Request for Public RecordsAdminpdfadmin

MDHHS-5926

Habilitation Supports Waiver (HSW) – Application WorksheetMDHHSpdfmdhhs

MDHHS-3894

Habilitation Supports Waiver (HSW) – Eligibility CertificationMDHHSpdfmdhhs

MDHHS-5927

Habilitation Supports Waiver (HSW) – Performance on Major Life ActivityMDHHSpdfmdhhs

0828

Harassment ComplaintHuman Resourcespdfhuman-resources

HCBS-NR

HCBS Non-Residential Provider ApplicationOtherdocxother

HCBS-R

HCBS Residential Provider ApplicationOtherdocxother

0055

Health Care ChronologicalHealth & Medicalpdfhealth-medical

0730

Henry Ford Employer Solutions: Employer Authorization for Treatment/BillingSupervisorypdfsupervisory

0805

Hepatitis B Vaccine Consent / WaiverHuman Resourcespdfhuman-resources

0918

Hospital DischargeHealth & Medicalpdfhealth-medical

0913

Incident of Weapons and/or Drugs in the WorkplaceSafetypdfsafety

0057

Incident ReportClinicalpdfclinical

0146

Individual Plan of Service (IPOS) Training LogClinicalpdfclinical

0316

Individual ProfileClinicalpdfclinical

0725

Industrial Health – Medical AuthorizationSupervisorypdfsupervisory

0160

InSHAPE – OrientationHealth & Medicalpdfhealth-medical

0163

InShape, Bfit, Health Matters – Self Health Action Plan for EmpowermentHealth & Medicalpdfhealth-medical

0161

InShape, Bfit, Health Matters ReferralHealth & Medicalpdfhealth-medical

0162

InShape, Bfit, Health Matters- Medical ClearanceHealth & Medicalpdfhealth-medical

0002A

Installment Payment Agreement – Hospital InpatientClinicalpdfclinical

0004

Installment Payment Agreement – OutpatientClinicalpdfclinical

0002

Installment Payment Agreement – Specialized ResidentialClinicalpdfclinical

0236

Instructor Confidentiality AgreementAdminpdfadmin

0392

Intensive Care Coordination w/ Wraparound (ICCW) – Crisis/Safety PlanClinicalpdfclinical

0339

Intensive Care Coordination w/ Wraparound (ICCW) – Graduation SummaryClinicalpdfclinical

0394

Intensive Care Coordination w/ Wraparound (ICCW) – Initial PlanClinicalpdfclinical

0397

Intensive Care Coordination w/ Wraparound (ICCW) – Needs AssessmentClinicalpdfclinical

0399

Intensive Care Coordination w/ Wraparound (ICCW) – Team MembersClinicalpdfclinical

0337

Intensive Care Coordination w/ Wraparound (ICCW) – Transition PlanClinicalpdfclinical

1304

Level 1 Authorization Training AttestationAdminpdfadmin

0280

Location MaintenanceIT & OASISpdfit-oasis

0073

Maintenance / Repair RequestSafetypdfsafety

0121

Medicaid Deductible WorksheetClinicalpdfclinical

0050

Medical Appointment Information RecordHealth & Medicalpdfhealth-medical

0231

Medical Records – Records Request InquiryAdminpdfadmin

0059

Medical Release of Information – Consent for Hepatitis B / HIV Blood Testiing (This Form is for SUD Use Only)Health & Medicalpdfhealth-medical

0384

Medication – DeliveryHealth & Medicalpdfhealth-medical

0305

Medication – DisposalHealth & Medicalpdfhealth-medical

0311

Medication – Genoa Refill RequestHealth & Medicalpdfhealth-medical

0048

Medication Administration RecordHealth & Medicalpdfhealth-medical

0049

Medication CountsHealth & Medicalpdfhealth-medical

0049A

Medication Counts – Day ProgramsHealth & Medicalpdfhealth-medical

0051

Medication Error ReportHealth & Medicalpdfhealth-medical

0008

Medication TransferHealth & Medicalpdfhealth-medical

0340

Mental Health Services Emergency Pre-Admission ScreeningClinicalpdfclinical

0388

Mental Health Treatment Order – Non-Compliance Pick-Up OrderClinicalpdfclinical

0841

Mentoring Program – Mentee ApplicationHuman Resourcespdfhuman-resources

0843

Mentoring Program – Mentee Progress NoteHuman Resourcespdfhuman-resources

0840

Mentoring Program – Mentor ApplicationHuman Resourcespdfhuman-resources

0842

Mentoring Program – Mentorship Agreement and Personal Development PlanHuman Resourcespdfhuman-resources

0206

Mobile Device Letter of AgreementIT & OASISpdfit-oasis

0370

No Identification or Decline to Provide IdentificationClinicalpdfclinical

0115

Non-Crisis Group Home Agency ProfileClinicalpdfclinical

1039

Notice of DisclaimerClinicalpdfclinical

0733

Notification of Employee Performance ReviewSupervisorypdfsupervisory

0286

OASIS Refresher TrainingIT & OASISpdfit-oasis

0334

Objective Opiate Withdrawl Scale (OOWS)Health & Medicalpdfhealth-medical

0253

On Call TimesheetFinancexlsxfinance

0601

Opportunity for Improvement PlanSupervisorydocxsupervisory

1301

Organization ApplicationAdminpdfadmin

1302

Organizational Deemed Status RequestAdminpdfadmin

0254

Overnight Per Diem WorksheetFinancepdffinance

0806

Overtime DocumentationHuman Resourcespdfhuman-resources

0120

Parent(S) Financial Determination for Minor Children (Less Than 18yrs.) Receiving Specialized Residential ServicesClinicalpdfclinical

0274

Patient Responsibility AgreementFinancepdffinance

0274

Patient Responsibility Agreement (Spanish)Financepdffinance

0124

Periodic Review Sheet for BTPRC Behavior PlansClinicaldocxclinical

0826

Personal Use of Any Cell Phone During Paid Working HoursHuman Resourcespdfhuman-resources

0830

Personnel Change of InformationHuman Resourcespdfhuman-resources

0261

Petty Cash RequestFinancepdffinance

0179

Physician Referral for DietitianHealth & Medicalpdfhealth-medical

0154

Port of Hopes Inc.: Drop-In Center Eligibility VerificationClinicalpdfclinical

0125

Positive Behavior Supports SurveyClinicalpdfclinical

1300

Practitioner Application Network Enrollment and CredentialingAdminpdfadmin

0736

Pre-Employment Notification and AcknowledgementHuman Resourcespdfhuman-resources

0225

Prescriber Case Consultation RequestAdminpdfadmin

0222

Prescriber Peer ReviewAdminpdfadmin

1023

Prescription for Occupational Therapy(OT) ServicesHealth & Medicalpdfhealth-medical

0228

Program Performance Indicator (PI) Plan of CorrectionAdminpdfadmin

0041

Program Placement / Transfer MeetingClinicalpdfclinical

0041C

Program Placement / Transfer Meeting – Transfer Checklist (Optional)Clinicalpdfclinical

0726

Program Supervisory Plan OutlineSupervisorypdfsupervisory

0221

Provider Enrollment Information and ConsentAdminpdfadmin

0281

Provider Enrollment – Update or Disenrollment for OASISIT & OASISpdfit-oasis

0256

Purchase OrderFinancexlsxfinance

0285

Quality Improvement Plan (QIP)Clinicalpdfclinical

0740

Reasonable Suspicion Determination ReportHuman Resourcespdfhuman-resources

MDHHS-0030

Recipient Rights ComplaintMDHHSpdfmdhhs

KIDS

Referral – Kids in Distress Services, Inc.Otherpdfother

0144

Referral – SuboxoneHealth & Medicalpdfhealth-medical

SAL-0001

Referral for the Salvation Army Social Service DepartmentOtherpdfother

MDHHS-3471

Referral Form – DHS/ SSAMDHHSpdfmdhhs

0327

Referral – Employment Services (IPS)Clinicalpdfclinical

0354

Referral – Intensive Care Coordination w/ Wraparound (ICCW)Clinicalpdfclinical

1306

Region 10 Conflict of Interest Attestation – Entity ProviderAdminpdfadmin

1305

Region 10 Conflict of Interest Attestation – Individual ProviderAdminpdfadmin

0373

Release – ActorClinicalpdfclinical

0374

Release – ArtworkClinicalpdfclinical

0380

Release – Authorization for Release of Information for Staff TestimonyClinicalpdfclinical

0382

Release – Newsletters, Annual Reports, Public Relations, and Related UsesClinicalpdfclinical

0375

Release – Video/PhotographClinicalpdfclinical

0376

Release – WritingClinicalpdfclinical

MDHHS-3200

Report of Actual or Suspected Child Abuse or NeglectMDHHSpdfmdhhs

0007

Request for a New Rate DeterminationClinicalpdfclinical

0715

Request for a Temporary Assignment or Temporary EmploymentSupervisorypdfsupervisory

0917

Request for Amendment of Protected Health InformationClinicalpdfclinical

0815

Request for Leave of AbsenceHuman Resourcespdfhuman-resources

0282

Request for New Location CodeIT & OASISpdfit-oasis

0232

Request for Policy / Administrative Procedure ExceptionAdminpdfadmin

0031

Request for Transfer to an Alternate PrescriberClinicalpdfclinical

0825

Request for Tuition/Training/Endorsement/Certification ReimbursementHuman Resourcespdfhuman-resources

0104

Request for Voluntary Discharge from ServicesClinicalpdfclinical

0223

Request to Create New GroupAdminpdfadmin

0264

Request to Send Responsible Party to the Credit Bureau or Write-Off AccountFinancepdffinance

0271

Request to Waive Assessed Ability to Pay or Fee Per SessionFinancepdffinance

BCAL-2319

Resident FundsOtherpdfother

0832

Return to Work Commitment – Paid Parental LeaveHuman Resourcespdfhuman-resources

1021

Review of OT/PT Services (Medicare only)Health & Medicalpdfhealth-medical

1038

Safety In-Home Training ChecklistClinicalpdfclinical

0734

Sample Letter of Completion of Probationary PeriodSupervisorypdfsupervisory

0224

SCCCMH Conflict of Interest DisclosureAdminpdfadmin

0047B

Seizure – Historical Seizure ReportHealth & Medicalpdfhealth-medical

0047

Seizure – Report of SeizureHealth & Medicalpdfhealth-medical

0306

Self-Administration of Medication (SAM) Assessment ToolHealth & Medicalpdfhealth-medical

0307

Self-Administration of Medication (SAM) Weekly LogHealth & Medicalpdfhealth-medical

0123

Sentinel Event Root Cause Analysis (RCA)Clinicaldocxclinical

0276

Sliding Fee Discount Program HandbookFinancepdffinance

0070

SOAR ReferralClinicalpdfclinical

0247

Special Committee/Advisory Council Member VoucherFinancepdffinance

0025C

Special Consent Behavior Treatment InterventionClinicalpdfclinical

0257

Special Fund Account RequestFinancepdffinance

0117

Specialized Group/Foster Homes or Inpt >60 days – Earned Income WorksheetClinicalpdfclinical

0118

Specialized Group/Foster Homes or Inpt >60 days – Fee Determination for Mental Health ServicesClinicalpdfclinical

0116

Specialized Group/Foster Homes or Inpt >60 days – Financial Ability to Pay Agreement: Summary & Signature PageClinicalpdfclinical

0119

Specialized Group/Foster Homes or Inpt >60 days – Full Financial Review Income/Expenses AnalysisClinicalpdfclinical

1024A

Specialized Residential Personal Care and Community Living Supports LogClinicalpdfclinical

0091

Specialized/Enhanced Medical Equipment and Supplies, Environmental Modifications and/or Enhanced PharmacyClinicalpdfclinical

0359

Spravato – Hamilton Depressing Rating Scale (HAM-D)Health & Medicalpdfhealth-medical

0360

Spravato – Questionnaire Regarding History of DissociationHealth & Medicalpdfhealth-medical

0361

Spravato – Screening QuestionsHealth & Medicalpdfhealth-medical

0258

Staff Credit Card RequestFinancepdffinance

0728

Staff Meeting TrainingSupervisorypdfsupervisory

0383

Staff Task TrackerAdminpdfadmin

1400

Staff Training RequestTrainingpdftraining

0029A

Standing Medication OrderHealth & Medicalpdfhealth-medical

0029B

Standing Medication Order – List for Children Ages 2 through 11 Years of AgeHealth & Medicalpdfhealth-medical

0029C

Standing Medication Order – List for Individuals 12 Years of Age and OlderHealth & Medicalpdfhealth-medical

0029

Standing Medication Order – MissedHealth & Medicalpdfhealth-medical

SSA-1945

Statement Concerning Your Employment in a Job Not Covered by Social SecuritySSApdfssa

0824

Student / Volunteer – Information/AuthorizationHuman Resourcespdfhuman-resources

0820

Student / Volunteer Data SheetHuman Resourcespdfhuman-resources

0821

Student EvaluationHuman Resourcespdfhuman-resources

0823

Student Placement ProposalHuman Resourcespdfhuman-resources

0345

Student Pre-Screen DispositionClinicalpdfclinical

0822

Student Request for PlacementHuman Resourcespdfhuman-resources

0333

Subjective Opiate Withdrawl Scale (SOWS)Health & Medicalpdfhealth-medical

LARA-210

Substance Use Disorder Programs – Complainants Appeal to the Regional Entity Rights ConsultantLARApdflara

LARA-225

Substance Use Disorder Programs – Departments Investigation ReportLARApdflara

LARA-205

Substance Use Disorder Programs – Program Rights Advisors Investigation ReportLARApdflara

LARA-220

Substance Use Disorder Programs – Recipient Rights Appeal to the DepartmentLARApdflara

LARA-200

Substance Use Disorder Programs – Recipient Rights Complaint FormLARApdflara

LARA-215

Substance Use Disorder Programs – Regional Entity Rights Consultant Investigation ReportLARApdflara

0378

Substance Use Disorder Services Program: Attestation Statement/Policy ReviewHuman Resourcespdfhuman-resources

0067

Summary Report for GuardianshipClinicalpdfclinical

0729

Supervisor FeedbackSupervisorypdfsupervisory

FTOC

Table of Contents: FormsTable of Contentspdftable-of-contents

TOC

Table of Contents: PoliciesTable of Contentspdftable-of-contents

0723

Telephone Reference CheckSupervisorypdfsupervisory

0260

Travel/Expense VoucherFinancexlsxfinance

0068

Treatment AgreementClinicalpdfclinical

0332

Urine Drug Screen Result RecordHealth & Medicalpdfhealth-medical

0238

Utilization Management Affirmation Statement About IncentivesAdminpdfadmin

1044

Utilization Review Reconsideration and DispositionClinicalpdfclinical

0813

Vacation Cap Variance RequestHuman Resourcespdfhuman-resources

0804

Variable Work ScheduleHuman Resourcespdfhuman-resources

0343

Waiver – Choking IncidentHealth & Medicalpdfhealth-medical

0348

Waiver – Trauma-Informed Yoga Liability Waiver & ReleaseHealth & Medicalpdfhealth-medical

0833

Worker’s Compensation Disclaimer for InternsHuman Resourcespdfhuman-resources

0814

Working Remotely PacketHuman Resourcespdfhuman-resources

0178

Wraparound Request for Services- GAP Pool FundsClinicalpdfclinical

0318

Youth Peer Support Specialist (YPSS) Consumer ProfileClinicalpdfclinical