Provider Forms
Please mail applications and correspondence to:
Provider Relations Department
Southeastern Center for MH/DD/SAS
P.O. Box 4147
Wilmington, N.C. 28406-4147
For independent, direct-enrolled providers, please submit the following documents:
- Independent Performing Provider
Profile (with attachments)
- SEC Memorandum of Agreement (Practitioner)
Please submit three (3) original, signed MOAs - Referral Procedure for Direct Enrolled Providers
- Request for Referral
Submit to Care Management Unit to receive a referral number for child & youth consumers.
- Request for Referral
For Community Provider agencies, please submit the following documents with the contract request form:
- Provider Network Enrollment Application (with attachments)
- W-9 Form
- Contract Checklist - Insurance Requirements
Below is an alphabetical list of forms that may be downloaded. Providers may add their letterhead and otherwise adapt existing Southeastern Center forms as needed.
- Address/Contact Person Change Form
- Assignment of Benefits
- At-Risk (CMSED) Enrollment/Re-Enrollment & Consent
- Authorization for Use & Disclosure of
Protected Health Information
- Batch Cover Sheet
- Billing Correction Form
- CAP Requisition Form
- CAP MR/DD Referral Form
- Child & Youth Disclosure
- Client Rights Brochure - Adult
- Client Rights Brochure - Child/Youth
- Consumer Placement Change
- Consumer Complaint
- Contract Checklist - Attachment/Insurance Requirements
- Crisis Prevention/Crisis Response
- DHHS Incident and Death Report Form
- DHHS Quarterly Incident Report
- DHHS Restrictive Intervention Details Report Form
- Documentation Tracking Log
- DMH Endorsement Page
- EPSDT Review Request
- EPSDT Review
- Form B - Demographic Sheet
- Facility Status Review
- Health Care Registry 24-Hour Report Form
- Health Care Registry 5-Day Report Form
- HIPAA Privacy Notice
- Initial Service Notification
- Insurance Authorization
- IPRS - DD, Adult
- IPRS - DD, Child
- IPRS - MH, Adult
- IPRS - MH, Child
- IPRS - SA, Adult
- IPRS - SA, Child
- NC-SNAP
- Notification of Out of Home Placement (C/Y consumers
-
PCP - Consumer Admission Form
-
Person Centered Plan Complete
-
PCP Introductory
-
Person Centered Plan Complete
- Peer Support Group Flyer
- Peer Specialist Certification
- Post Payment Review Plan of Correction Form
- Provider Network Application
- Provider Choice Acknowledgement
- Provider Monitoring Checklist
- Residential Checklist
- Safety & Supervision Planning Checklist
- Service Activity Log
- Service Orders
- State Facility Residential Applications for Child/Youth:
- Strategic Objectives Template
- Supportive Housing Forms
- Treatment/Discharge Summary
- Value Options Forms:
