County Human Services

Forms & Instructions

Having Problems accessing your addiction treatment benefits? 

Information on Act 106: Link to fileDownload

 

DDAP Assessment

Title Sixe (Kb) Link to File
 

SCA Funding Request for Authorization Packet

Title English Español
RFA -Request for Authorization - 8/10/21 Download  
Client Rights Notification -  2/27/14 Download  
Grievance and Appeal Proccess - 8/22/19        Download  
General Consent to Release - 2/27/14 Download Download
Consent for Redisclosure - 2/27/2014 Download Download
Methadone Maintenance Treatment Agreement  - 9/1/13 Download  

* Only applicable to Methadone providers
 

INSTRUCTIONS: Accessing SCA Funding Request for Authorization Packet                                                                                                                                                                                                             

 
In-patient - Work in Progress Download
Out-patient - Work in Progress Download

 

Liability Determination Forms

Title Size (Kb)  
Liability Determination Form - 8/1/2018 31.48 Download
Request for Liability Reduction - 7/2/14 33.30 Download
Liability Determination Tables  n/a Link to DDAP
 
 

Wellness Court Forms

Title Size (Kb)  
Treatment Update Report Form -  8/20/19 53 Download

 

Fiscal Forms

   
HDA310 Form For Outpatient FY 20-21   Download
HDA310 Form for Inpatient  FY 2020-2021   Download
HDA311 Budget Form (Cost Reimbursed Contracts Only)     97 Download
HDA310 Addendum 208 Download
Password Protect File Instructions   Download
Case Management Invoicing Report   Download

 

YADAC Report Forms

   
Title Size (Kb)  
YADAC Outcome Measures Form 551 Download