Forms

Medicaid MCO Documentation  

• FY21 State Medicaid Contract
• Record of Persons Served
• FY21 Area Plan, Fee Schedule and COOP Plan

Preferred Practice Guidelines - Draft 
subject to revision

• PPGs with ROSC principles

Treatment MIS Manual, Forms and Codes

• Provider Contract Training 6/26/17
• Performance Improvement Project (PIP)
• SFY2019 State Division Directives with Updated MCOT Language
• SFY2015 Documentation Requirements
• FY19 Treatment Rate Table
• SUD UM Submission Form
• FY2017 Budget Form
• Referral to VBH Forensics for Medication Evaluation
• Referral to VOA - Cornerstone for Medication Evaluation
• ASAM Assessment Tool
• SUD UM Policy
• UM Policy Funding Chart
• HIPAA/HITECH Training

Financial - Co-Pay Schedule

• FY22 Treatment Co-Pay Schedule and Methodology

Notice of Action & Appeal forms

• Actions That Require a Notice of Action
• Notice of Action Template to Decrease or End Services
• Appeal Instructions to Action to Decrease or End Services
• Notice of Action Template for All Other Actions 
• Appeal Instructions to Action for All Other Actions
• Appeal Request Form

Access to Recovery

To apply for the Access to Recovery (ATR) RFP, please go through zoom grants. Select the RSS/ATR application.

Prevention Services

Prevention Services has been permanently moved to the Salt Lake County Health Department. Please click here to access the Prevention Services website at the Salt Lake County Health Department.