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
1EditEA-214TANF 6 Month Report FormDelete
1EditBH-11cAdult SUD Discharge Outcome Tool Delete
1EditCCSOrientation Training Verification FormDelete
1EditSE-492Notice of Shared Medical ExpensesDelete
1EditCCSElectronic Payment ExemptionsDelete
1EditEA-320Self-Employment LedgerDelete
1EditBH-11eAdult MH Update Outcome ToolDelete
1EditBH-13eFamily MH Update Outcome ToolDelete
1EditOS-954Client Authorized Debit for Repayment of OverissuanceDelete
1EditBH-04102b Hardship ConsiderationsDelete
1EditCPSProvider Mileage RequestDelete
1EditCPS-533Adoption Registry FormDelete
1EditDSSPsychiatric Residential Treatment Facility Referral FormDelete
1EditMSMedicaid Non-Emergency Travel (NEMT) Payment Authorization FormDelete
1EditEA-347Application for Social Security NumberDelete
1EditSE-415Petition for Modification FormDelete
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
1EditCPS-549Request for Screening for Substantial Reports of Abuse and Neglect (unregistered family day care providers ONLY)Delete
1EditCPSBackground Information for Voluntary Termination of Parental RightsDelete
1EditEA-297Energy Assistance ApplicationDelete
1EditCPSPlacement Resource Monthly Reporting Form Ages 0-4Delete
1EditEA-269Child Care Expense Billing InformationDelete
1EditSE-405Application for Income Withholding Only ServiceDelete
1EditEA-298Weatherization ApplicationDelete
1EditBH-11bAdult SUD Update Outcome ToolDelete
1EditDSS-ORFI-831Estate Recovery Notification of Death FormDelete
1EditEA-301SNAP ApplicationDelete
1Edit Recipient Forms: HIPAA Privacy Consent FormDelete
1EditEA-301Economic Assistance ApplicationDelete
1EditENERGYVendor Information: Direct DepositDelete
1EditCPSIndependent Living Program Education and Training Voucher Delete
1EditEA-305Boarding School-Institution DocumentationDelete
1EditBH-09aIndigent Medication Update-Extension ApplicationDelete
1EditRec and FraudCasualty Settlement Report FormDelete
1EditMS-102Provider Selection FormDelete
1EditEA-208Authorization to Furnish / Release InformationDelete
1EditEA-260Statement of EarningsDelete
1EditBH-09Indigent Medication ApplicationDelete
1EditEA-310Form for Reporting ChangesDelete
1EditEA-269Child Care Expense Billing InformationDelete
1EditSE-431AChild Support Payment Authorization FormDelete