Client Forms & Instructions

Having Problems accessing your addiction treatment benefits? 

Single County Authority (SCA) Funding Request for Authorization Packet

English

  1. Request for Authorization (RFA) - 8/10/21 (DOCX)
  2. Client Rights Notification - 2/27/14 (PDF)
  3. Grievance and Appeal Proccess - 8/22/19 (PDF)
  4. General Consent to Release English - 2/27/14 (PDF)
  5. Consent for Redisclosure English - 2/27/2014 (PDF)
  6. Methadone Maintenance Treatment Agreement - 9/1/13 - Only Applicable to Methadone Providers (PDF)

Spanish

  1. General Consent to Release Spanish - 2/27/14 (PDF)
  2. Consent for Redisclosure Spanish - 2/27/2014 (PDF)

Liability Determination Forms

Wellness Court Forms

  1. Treatment Update Report Form - 3/23/2022 (PDF)

Fiscal Forms

  1. Case Management Invoicing Report (XLSX)
  2. HDA310 Addendum (XLS)
  3. HDA310 Form for Inpatient FY 2020 to 2021 (XLSX)
  4. HDA310 Form For Outpatient FY 20 to 21 (XLS)
  5. HDA311 Budget Form (Cost Reimbursed Contracts Only) (XLS)
  6. Password Protect File Instructions (PDF)

York / Adams Drug & Alcohol Commission Report Forms

  1. York Adams Drug and Alcohol Commission Outcome Measures Form (XLS)