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 Size (Kb) English Español
Services Rendered Form - DDAP-EFM-1006 12/1/15 59.15 Download  
RFA - Updated 9/13/18 121.76 Download  
Client Rights Notification - Updated 2/27/14 22.53 Download  
Charitable Choice Disclosure - Updated 2/28/14 9.21 Download  
Grievance and Appeal Proccess - Updated 2/27/2014         33 Download Download
General Consent to Release - Updated 2/27/14 50 Download Download
Consent for Redisclosure - Updated 2/27/2014 49 Download Download
Methadone Maintenance Treatment Agreement  - 9/1/13 24 Download  
Treatment Agreement form -  Updated 2/27/14 ** 34 Download  

* Only applicable to Methadone providers
** Only applicable if requested. 

INSTRUCTIONS: Accessing SCA Funding Request for Authorization Packet                                                                                                                                                                                                             

 
In-patient Download
Out-patient Download

 

 

 

Liability Determination Forms

Title Size (Kb)  
Liability Determination Form - Updated 8/1/2018 31.48 Download
Request for Liability Reduction - Updated7/2/14 33.30 Download
Liability Determination Tables - 2018-2019 n/a Link to DDAP
 
 
 

Wellness Courts/DRC  Forms, Etc.

Title Size (Kb)  
Treatment Update Report Form - Updated  1/04/19 53 Download
Consent For Redisclosure - Updated 2/27/14 49 Download
Non-Revocable Release - Updated 8/24/18 49 Download

 For more Treatment Court information, please visit: Adult Probation

 

Fiscal Forms

   
Title Size (Kb)        
HDA310 Budget Form 36 Download         
HDA311 Budget Form (Cost Reimbursed Contracts Only)     97 Download
HDA310 Addendum 208 Download
Password Protect File Instructions   Download

 

 

YADAC Outcome Measures

   
Title Size (Kb)       
YADAC Outcome Measures Form                                        551 Download