M. Greg DeSautel, MD
Cabinet Secretary

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Below you will find the selected forms and/or publications for this order. You will need to indicate the quantity you want to receive in the box next to the document number. After you have entered the quantity, click "Update" in the previous box. If you wish to remove a form or publication, simply click on the link that states "Delete." Once you have entered the quantity for each form or publication, click the "Proceed" button at the bottom.

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CopiesEdit the Number of CopiesDocument NumberDocument NameDelete
1EditBH-07Mental Health - Accreditation ApplicationDelete
1EditBH-11aAdult SUD Initial Outcome ToolDelete
1EditOS-950Recipient Forms: Title XIX Medical Transportation ReimbursementDelete
1EditEA-324Wage VerificationDelete
1EditCCSPathways to Professional Development - Career Lattice Application FormDelete
1EditCPS-508Reference Form - Adoption / Foster / Kinship CareDelete
1EditSE408CPApplication and Agreement for Services - Custodial Parent and/or CaretakerDelete
1EditBRO/CPS17Family Group Conferencing – Parents Guide Delete
1EditBRO/CPS4Mandatory Reporting of Child Abuse & Neglect BrochureDelete
1EditEA-214TANF 6 Month Report FormDelete
1EditBRO/EA16Medical Assistance for Children and Families: IHS SpecificDelete
1EditBH-11cAdult SUD Discharge Outcome Tool Delete
1EditBRO/CPS1Child Protection Services BookletDelete
1EditPosterCHIP PosterDelete
1EditCCSOrientation Training Verification FormDelete
1EditSE-492Notice of Shared Medical ExpensesDelete
1EditBRO/CPS7Independent Living Program Education and Training Voucher BrochureDelete
1EditBH-17Prevention - Accreditation ApplicationDelete
1EditCCSElectronic Payment ExemptionsDelete
1EditBRO/DSS8Notice of Privacy BrochureDelete
1EditEA-320Self-Employment LedgerDelete
1EditBH-11eAdult MH Update Outcome ToolDelete
1EditBRO/EA12Energy Assistance BrochureDelete
1EditBRO/CPS2Common Sense Parenting BrochureDelete
1EditBRO/RE4Medicaid Liens BrochureDelete
1EditBH-13eFamily MH Update Outcome ToolDelete
1EditEA-265Request for Long-Term Care or Home Community Based Services Waiver AssistanceDelete
1EditOS-954Client Authorized Debit for Repayment of OverissuanceDelete
1EditBH-04102b Hardship ConsiderationsDelete
1EditCPSProvider Mileage RequestDelete
1EditCPS-533Adoption Registry FormDelete
1EditPosterReportable Disease List PosterDelete
1EditDSSPsychiatric Residential Treatment Facility Referral FormDelete
1EditBRO/DSS3Administrative Hearings BrochureDelete
1EditMSTitle XIX Non-Emergency Transportation Payment Authorization FormDelete
1EditEA-347Application for Social Security NumberDelete
1EditSE-415Petition for Modification FormDelete
1EditBRO/EACommunity Action Agency HandoutDelete
1EditDSS-CCSRate Declaration FormDelete
1EditSE-406Application for Location Only ServicesDelete
1EditBH-18Substance Use Disorder High Intensity Referral FormDelete
1EditPAPrior Authorization Forms: Durable Medical Equipment and NutritionDelete
1EditEA-307SNAP Exit FormDelete
1EditCPSICPC Financial and Medical PlanDelete
1EditPAPrior Authorization Forms: Private Duty Nursing & Extended Home Health ServicesDelete
1EditDSS-W9W-9 FormDelete
1EditBH-063rd Party Release of Information (ROI)Delete
1EditBRO/DCS6Voluntary Paternity Establishment Handbook and FormDelete
1EditBRO/CCS3Registration & Licensure of Child Care EnvironmentsDelete
1EditBRO/EA14Medical Assistance for Children and FamiliesDelete
1EditEA-301MAChildren and Family Medical Assistance Supplemental Application Delete
1EditCPS-549Request for Screening for Substantial Reports of Abuse and Neglect (unregistered family day care providers ONLY)Delete
1EditBH-14Substance Abuse - Accreditation ApplicationDelete
1EditCPSBackground Information for Voluntary Termination of Parental RightsDelete
1EditCPS-522Request for PaymentDelete
1EditEA-297Energy Assistance ApplicationDelete
1EditCPSPlacement Resource Monthly Reporting Form Ages 0-4Delete
1EditEA-269Child Care Expense Billing InformationDelete
1EditBH-08Mental Health - IMPACT ApplicationDelete