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    Local Health Departments and Private Vendors

    Forms commonl​y used by the twenty-four Local Health Departments

    Schedule of Charges - DHMH 4411 A & B LHDSochargeA.doc
    LHDSochargeA.pdf
    FY 13 Non-Chargeable List FY13-NonChargeableList
    FY13-NonChargeableList
    FY 13 Out Patient Services - Ability to Pay Scale AbilitytoPayScheduleFY13OutpatientServices
    AbilitytoPayScheduleFY13OutpatientServices
    ADAA Halfway House, Long Term Care & Residential ICF - Ability to Pay Scale ADAA-AbilitytoPayScheduleFY13
    ADAA-AbilitytoPayScheduleFY13
    FY 13 Adult Day Care Services - Ability to Pay Scale ADC-AbilitytoPayScheduleFY13
    ADC-AbilitytoPayScheduleFY13
    MHA Residential Program Fee Determination (effective 7/1/05) feeform.pdf
    Worksheet to be used for Halfway House, Long Term Care & Residential ICF FY13-ADAA-ATPS-Instructions-Revised-6-11.doc
    FY13-ADAA-ATPS-Instructions-Revised-6-11.pdf
    Instructions for completing the MH Residential Fee Form MHFeeDeterminationInst.doc
    MHfeeDeterminationInst.pdf
     

    Forms commonly used by the Private Vendors:

    Schedule of Charges - DHMH 4411 A & B ADAA4411aschedule.doc
    ADAA4411aschedule.pdf ADAA4411bschedule.xls
    ADAA4411bschedule.pdf
    ADAAdefinition4411b.doc
    ADAAdefinition4411b.pdf
    FY 13 Non-Chargeable List FY13-NonChargeableList
    FY13-NonChargeableList
    FY 13 Out Patient Services - Ability to Pay Scale AbilitytoPayScheduleFY13OutpatientServices
    AbilitytoPayScheduleFY13OutpatientServices
    ADAA Halfway House, Long Term Care & Residential ICF - Ability to Pay Scale ADAA-AbilitytoPayScheduleFY13.xls
    ADAA-AbilitytoPayScheduleFY13.pdf
    FY 13 Adult Day Care Services - Ability to Pay Scale ADC-AbilitytoPayScheduleFY13
    ADC-AbilitytoPayScheduleFY13
    MHA Residential Program Fee Determination (effective 7/1/05) feeform.pdf
    Worksheet to be used for Halfway House, Long Term Care & Residential ICF FY13-ADAA-ATPS-Instructions-Revised-6-11.doc
    FY13-ADAA-ATPS-Instructions-Revised-6-11.pdf
    Instructions for completing the MH Residential Fee Form MHFeeDeterminationInst.doc
    MHfeeDeterminationInst.pdf
     

    Forms Commonly used by the Fee Payment System Vendors

    Fee Payment System Invoice - DHMH 4356 fpysyinv.doc
    fpysyinv.pdf
    Fee Payment System Invoice - DHMH 4513 dhmh_4513.doc
    dhmh_4513.pdf