Providers' Page

Forms

Please mail applications and correspondence to:

Provider Services 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
SEC Memorandum of Agreement--Practitioner
Please submit one original, signed MOA
Referral Procedure for Direct Enrolled Providers

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.

Add/Change Form
Assignment of Benefits
Authorization Checklist
Authorization for Use & Disclosure of Protected Health Information
Billing Correction Form
CAP Prioritization Request Form
CAP Requisition Form
Child & Youth Disclosure
Client Rights Brochure - Adult
Client Rights Brochure - Child/Youth
Consumer Residential Placement Change (rev. 8/10/09)
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
Direct Deposit Memo
Direct Deposit Authorization Form
Disaster Plan Update
Documentation Tracking Log
DMA Endorsement Applications
DMH Endorsement Page
EPSDT Review Request
EPSDT Review
Form B - Demographic Sheet
- Mandatory Fields
Health Care Registry 24-Hour Report Form
Health Care Registry 5-Day Report Form
HIPAA Privacy Notice
Initial Service Notification (rev. 1/9/09)
Insurance Authorization
IPRS Target Population Enrollment Form, Child
IPRS Target Population Enrollment Form, Adult
IRS Form W-9: Request for Taxpayer Identification Number and Certification
Late Payment Follow-Up
Notification of Out of Home Placement (C/Y consumers
Peer Specialist Certification
Person Centeredness Page on DMH website
Plan of Correction Form
Provider Network Enrollment (rev. 6/10) Additional Licensed Staff enrollment separate pages.
Provider Choice Acknowledgement
Provider Complaint Clarification
Record Retention Log
Re-Endorsement Attestation Letter
Re-Endorsement Attestation Letter (CAP Svcs)
Residential Checklist
Risk Assessment
Safety & Supervision Planning Checklist
Service Activity Log
Service Orders
Sliding Fee Schedule (Sample)
State Facility Residential Applications for Child/Youth:
- Wright School
- Whitaker School
- PRTF
Strategic Objectives Template
Supportive Housing Forms
Transition Committee Referral Form
Transition Committee Release Form
Treatment/Discharge Summary
Value Options Forms:
- CAP-TCM Request for Authorization (CTCM)
  - Instructions
- Inpatient Treatment Report (ITR)
  - Instructions
- Outpatient Review Form (ORF2)
  - Instructions
- Value Options Certification Letter Request Form