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    • Single Case Agreement Application
      • Electronic
      • Printable
      • SCA Required Attachments
  • Home
  • About
    • Careers
  • Whole Person Care
    • Medicaid Transformation
  • Members and Families
    • Access to Care
    • Adults and Children with Developmental Disabilities and Mental Health Concerns
    • CFAC
    • Community Resources
    • Complaints, Grievances and Appeals
    • Complex Care Management for Children
    • Emergency Preparedness
    • Housing
    • Innovations
    • Joining Meetings With Your Computer or Mobile Device
    • Member Resources
    • Member Rights
    • myStrength
    • Program Referral Forms
    • Traumatic Brain Injury (TBI)
    • Veterans
  • Provider
    • AlphaMCS Provider Portal
    • Authorization (UM) and Benefits Packages
    • Becoming a Provider
    • Contracting and Payment
    • Information, Manuals and Forms
    • Meetings and Trainings
      • Crisis Intervention Team (CIT)
      • Mental Health First Aid Training
    • NC HealthConnex
    • Program Integrity
    • Provider Council
    • Quality Management
    • Request Technology Support
    • Residential Vacancy
  • Contact
  • Report Fraud and Abuse
  • Quick Access
    • 211.org
    • Adding a Provider Site /Moving a Provider Site Form
    • Clinical Coverage Policies
      • Medicaid
      • State
    • Division of Health Benefits
    • Eastpointe Benefit Plan
      • Medicaid Funded
      • State Funded
    • Eastpointe’s Provider Choice Database
    • Eastpointe Provider Orientation Manual
    • Eastpointe Rate Sheet
    • Eastpointe Training Calendar
    • NC Division of Mental Health/Developmental Disabilities and Substance Abuse Services’
    • NCTRACKS
    • Provider Meeting Documentations/Handouts
    • Single Case Agreement Application
      • Electronic
      • Printable
      • SCA Required Attachments

Forms

Downloadable Forms

ACT Team ATR Information

Authorization Request Transfer Form

Caswell Foundation

Certificate of Need Inpatient

Child and Adolescent System of Care Form

Credentialing

Criteria 5

Disaster Forms

Provider Participant for Disaster Shelter Form Smartsheet

Innovations

Mobile Crisis Team

Plan of Correction

Program Integrity

Provider Transition

PRTF

QI Template

Re-Credentialing

Referral form for State Hospital or Adatc

Registry of Unmet Needs

Relative as Provider

Treatment Authorization Request Form TAR

Updating Provider Information

Single Case Agreement

Single Case Agreement Required Attachments

TCLI Subsidy

Electronic Forms

Add/Move a Provider Site
Add Service
Care Review Referral Form
Common Name Data Service (CNDS) Form
Comprehensive Crisis Plan/Release of Information
Eastpointe Communication and Marketing Request for Review Form
Enhanced/Specialized Rate Request Form
Fidelity IPS‐Supported Employment (IPS‐SE) Participant ACH In/At Risk Checklist
First Commitment Waiver Notification Form
Initial/Final Caseload Transfer Form
Initial Reporting of Level 3 Incident Reports
Innovations Incident Reporting
JJSAMHP District 7 CLT Reporting Form
JJSAMHP Districts 13 and 16 CLT Reporting Form
JJSAMHP Districts 4 and 8 CLT Reporting Form
Medical Records Storage Notification
MHSU Care Coordination Referral Form
Mobile Crisis Disposition Form
NC -TOPPS Access Control
Person Centered Profile (PCP) Forms
Practitioner Initial and Change Form
Program Integrity Referral Form
Provider Change Form
Provider Listserv Sign-Up Form
Providers of NC Innovations COVID-19 related appendix K reporting
Single Case Agreement
Suggestion Box
TCLI Care Coordination Referral

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