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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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Release of Information (ROI) Template Updated August 23, 2018
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This is a sample template for a standard release of information form.

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IDHW-SUD Rate Matrix 1-15-2020 to Current Updated July 1, 2019
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To access the current IDHW SUD Rate Matrix please click here.

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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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Evidence Based Practice Form (SUD) Updated May 15, 2020
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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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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 15, 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 Status Report Form and Q&A Updated May 20, 2020
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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 Status Report Form

 

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Co-occurring Assessment Form Updated May 15, 2020
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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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Leave Our Networks Updated March 6, 2019
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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 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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IDHW General Consent for Release of Information Form Updated November 4, 2016
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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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Adverse Event Reporting Form Updated July 9, 2020
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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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PWWC Checklist Updated May 29, 2020
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The PWWC Checklist must be completed for all State funded PWWC clients. Checklist can be accessed here.

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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