Division of Cost Accounting

Local Health Departments and Private Vendors Forms

Forms commonly used by the twenty-four Local Health Departments
Schedule of Charges - DHMH 4411 A & B
LHDSochargeA.pdf
FY 18 Non-Chargeable List
FY 18 Out Patient Services - Ability to Pay Scale
BHA Halfway House, Long Term Care & Residential ICF - Ability to Pay Scale
FY 16 BHA ATPS Instructions
FY 16 Adult Day Care Services - Ability to Pay Scale
Worksheet to be used for Halfway House, Long Term Care & Residential ICF
BHA4411aschedule.doc Schedule of Charges - DHMH 4411 A & B
BHA4411aschedule.pdf 
BHA4411bschedule.xls
BHA4411bschedule.pdf 
BHAdefinition4411b.doc
BHAdefinition4411b.pdf