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SUD Provider Staff Update Form Updated November 21, 2018
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You are now able to add and/or remove SUD Provider Staff via the link below.  Please remember that adding staff requires documentation to include a valid IDHW CHU Enhanced Background Check confirmation. More information is found on the form. Please contact us if you have any questions 1-800-688-4013.

BPA Health SUD Staff Update Form

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BPA Health SUD Provider Initial Application Updated August 23, 2018
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SUD Add/Remove Address, Office Operations, and Specialty Attestation Form Updated November 28, 2018
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This form is used to add or remove an address, update office operations, update specialty attestation, and submit important documents.

 

https://www.cognitoforms.com/BPAHealth/SUDAddRemoveAddressForm

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Standard Release of Information Template Updated October 10, 2018
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This is a sample template for a standard release of information.

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SUD Provider Initial Application-Sample Updated September 26, 2018
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This document will allow you to preview the SUD application to assist you in preparing to complete the form.  To view the form, please click the download button.  To fill out the SUD Provider Initial Application, please click here.

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Child Welfare Case Termination Form Updated August 28, 2017
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Child Welfare Case Termination Form used to notify BPA Health a clients Child Protection case has been closed and will no longer be eligible to receive services funded through Child Protection Substance Use Disorder (CP/SUD).

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SUD Appeals Submission Form Updated October 25, 2018
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This form is for use by SUD Network providers when submitting an appeal.

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Pre-audit SUD Staff List Form Updated November 21, 2018
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The purpose of this form is to ensure we have up-to-date information on individuals working at your agency. Please complete the following for each of your staff members who interact with SUD clients and/or their medical records (examples: clinicians, clinical supervisors, case managers, recovery coaches, drivers, receptionist, billing staff, etc.) and submit at least one week prior to your audit.

To access the form, please click below or on the arrow above.

Pre-audit SUD Staff List Form

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SUD EB and Co-occuring Application Updated September 21, 2018
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Please click the link with the down arrow above to access a copy of the form that needs to be filled out.

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Encuesta de Seguimiento de Consentimiento Informado Updated November 2, 2018
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Encuesta de Seguimiento de Consentimiento Informado

Spanish Informed Consent for Follow-up Survey Form

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IDHW Memo to IROC MAT Prescribers Updated February 6, 2018
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IDHW Memo sent to IROC MAT Prescribers.  Includes a form that outlines the process for prescribers when working with funded clients

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Autorizacion para el uso o revelacion Updated August 15, 2017
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Autorizacion para el uso o revelacion de informacion a la agencia/entidad aprobada.

Spanish Release of Information form.

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IDOC Monthly Status Report Form and Q&A Updated November 27, 2018
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To view the communication from IDOC regarding this form, either please the link below or click the download button to the above right.

IDOC Status Report Communication

To access the IDOC Monthly Status Report Form directly, please click the link below:

IDOC Monthy Status Report Form

 

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IDHW General Consent for Release of Information Form Updated November 1, 2018
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20161104_Updated-IDHW-General-Release-Form

Release of information form for Idaho substance abuse treatment and recovery support services.

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Automatic Deposit Sign-up Form Updated August 31, 2018
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If you are an SUD Agency or EAP-BH Provider with BPA Health, we will electronically transfer funds directly into your account if you would like. Signing up for automatic deposits, also ensures a quicker turn-around time for you to receive your funds.

To sign up, please click below or click on the arrow above.

AUTOMATIC DEPOSIT SIGN-UP

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Co-occurring Assessment Update Form Updated November 21, 2018
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All treatment providers and sites in the BPA Health network must be co-occurring capable. Be prepared to demonstrate these capabilities in a co-occurring assessment form. This form is required to be submitted at time of facility renewal as well as any time a provider believes they may have moved from Capable to Enhanced.

To access the form, click on the arrow above.

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W-9 Form Updated November 21, 2018
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Request for taxpayer identification number (TIN) for reporting on an information return (e.g., 1099-MISC) the amount paid.

Click here for W-9 fillable form

 

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EBP Written Description Update Form Updated November 21, 2018
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The purpose of this form is to update BPA Health and the state with written descriptions of the Evidence-Based Practices (EBP) you are offering at each of your locations. Make sure to complete for any new EBPs you would like to offer as well as list any EBPs you are no longer offering.

To access the form, click the arrow above.

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Follow-up Survey Informed Consent Updated November 2, 2018
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Informed consent form for Substance Use Disorder Treatment Program follow-up surveys.

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Critical Incident/Sentinel Event Report Form Updated June 21, 2017
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Form for a provider to report a critical incident/sentinel event.