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SUD Provider Staff Update Form Updated January 4, 2023
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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 January 17, 2023
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SUD Add/Remove Address, Office Operations, and Specialty Attestation Form Updated January 10, 2023
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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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Release of Information (ROI) Template Updated August 1, 2022
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This is a sample template for a standard release of information form.

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IDHW-SUD Rate Matrix 4-25-2023 to Current Updated April 25, 2023
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To access the current IDHW SUD Rate Matrix click here

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IDOC SUD Rate Matrix – 10-01-2022 to Current Updated November 8, 2022
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To access the current IDHW SUD Rate Matrix please click here.

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SUD Provider Initial Application Updated January 4, 2023
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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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IDJC JJ-SUD Rate Matrix August 2021 Updated August 31, 2021
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To access the current IDJC JJ SUD Rate Matrix please click here.

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Evidence Based Practice Form (SUD) Updated January 4, 2023
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The purpose of this form is to inform BPA Health about the Evidence-Based Programs/Practices (EBP) you are offering at each of your locations. Make sure to complete for any EBPs you would like to add to your profile as well as those you are no longer offering.

To access the form, click here.

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Request for Service and Assessment Submission form Updated January 4, 2022
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Request for Service and Assessment Submission Form

This form is to be completed by providers who are submitting substance use disorder assessments (i.e. CDAs) other than GAINs in WITS for review and consideration of authorization of SUD funded services, including those not covered by Medicaid. In-network providers who have completed a GAIN should consent within WITS and NOT use this form.

Please be aware that your client must first call BPA Health at 1(800) 922-3406 and be screened for funding eligibility. Once funding eligibility has been met, please complete and submit this online form.  Any forms submitted prior to funding approval will be denied and you will be required to re-submit a new form after the screening has been completed.

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Authorization for Use and Disclosure Updated April 6, 2023
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Online Authorization for Use and Disclosure form: https://www.cognitoforms.com/BPAHealth/authorizationforuseanddisclosure

Printable Authorization for Use and Disclosure form: Authorization for Use and Disclosure

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Autorizacion para el uso o revelacion Updated September 1, 2022
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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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BPA Health Provider Manual Updated April 20, 2023
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The BPA Health Provider Manual, published in April 2023.

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IDHW General Consent for Release of Information Form Updated January 11, 2023
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20161104_Updated-IDHW-General-Release-Form

Release of information form for all State of Idaho funded substance use disorder treatment and recovery support services.

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Co-occurring Assessment Form Updated January 4, 2023
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All treatment providers and sites in the BPA Health SUD 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 here.

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Safe and Sober Housing Code of Ethics Updated September 1, 2022
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All Safe and Sober Housing Providers are required to adhere to this Code of Ethics:

20210113-SSH-Code-of-Ethics-1

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Leave Our Networks Updated June 7, 2022
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If you would like to be removed from the EAP or SUD Networks, please complete this brief form.

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

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Automatic Deposit Sign-up Form Updated June 1, 2022
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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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Appeals Submission Form Updated January 10, 2023
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Please click on this link to submit an appeal.

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

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Adverse Event Reporting Form Updated July 1, 2022
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All providers are required to report to BPA Health within 24 hours any incident or event that threatens the safe and efficient operations of BPA Health or any contracted provider, involving a client who received authorized services within the last thirty (30) days. Failure to comply with reporting requirements may result in sanctions.

The Adverse Event Reporting form can be accessed here.

A list of reportable events can be found here:

BPA Health may follow-up on adverse events for additional information.

 

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W-9 Form Updated May 31, 2022
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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