Local Health Departments and Private Vendors

Forms commonly 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

Local Health Departments and Private Vendors

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

Forms commonly used by the Private Vendors:

Forms Commonly used by the Fee Payment System Vendors

Forms commonly used by the twenty-four Local Health Departments