Forms

Our new Forms page contains a variety of frequently used forms for you to instantly download. Are we missing anything? If so, we want to know! Contact Nikki Adkins to suggest a new form or to get a hold of an old one.

Standardized Clinical Forms

The following are standardized clinical forms that are required for in-network contract service providers of LifeWays CMH. 

Ε  Ρ  Diagnostic Assessment - Update - Adult 

Ε  Ρ  Diagnostic Assessment - Update - Youth

Ε  Ρ  Med Drop Progress Note

Ε  Ρ  Supported Employment Progress Note

NEW FORMS: (Presented at Provider Meeting 1/10/2012)

Individual Progress Note

Pre-Planning

Residential Pre-Planning (Quality of Life Assmt)

Treatment Plan

Treatment Plan - Addtl Goal Page

Treatment Plan Addendum

Treatment Plan Review

Treatment Plan Review - Addtl Goal Page

If you have questions on the above New Forms, please contact Elizabeth Knoblauch.

Other Administrative and Clinical Record Forms

List of forms which depending on the item are of required format or are of suggested format for contract service providers of LifeWays CMH.

• Access Walk-In Demo Form
• Advanced Directive Form (LifeWays)
• Advanced Directive Form (MDCH, Bradley Geller)
• Ability to Pay e-Packet
• Behavioral Treatment Plan Data Sheet
• Case Closing - Request through BRMC
• Clinical Record Review Tool - Crisis Intervention
• Clinical Record Review Tool - Crisis Residential
• Clinical Record Review Tool - Crisis Stabilization
• Clinical Record Review Tool - Outpatient Services
• CODECAT Assessment Tool
• CO-FIT Assessment Tool
• COMPASS Assessment Tool
• Consent for Participation in Medical Services
• Consent for the Release of Confidential Information
• Consumer Demographic Information Form 1280 
• Consumer Guardian and Emergency Contact Information
• Credentialing Application - Organization
• Credentialing Application - Practitioner
• DD Proxy Measure Form 1283 - Instructions
• Drug Formulary for Medicaid Consumers
• Family Input Form
• Incident Report Form 
• Incident Report Indicator Codes
• Death Report Form
• Discharge Event
• Grievance and Appeal Form
• Health Care Communication Form
• Health Conditions Form 1287 - Instructions
• HCFA-1500 e-Form
• HIPAA Authorization Form
• HIPAA Consent Form
• Integrated Health New Consumer Health History
• Integrated Health Nurse Monitoring Note
• Integrated Health Nurse Monitoring Request
• Integrated Health Nursing Assessment
• Level of Care (LOC) Assessment Summary Form 1285 - Level of Care (LOC) Parameters for Assessment of Service Needs
• Memo to LifeWays Clinical Director - Request for Case Review
• Notice of Hearing Rights
• Personal Care (PC) and Comm. Living Supports (CLS) Checklist
• Psychiatric Service Communication Form
• Recipient Rights Complaint Form
• UM Request for Authorization Form 1286
• UM Request for Automatic Auth of Primary and Psychiatric Services Form 1284
• UM Request for Auth for Personal Care or Community Living Supports in Residential Setting Form 1282

Handouts and Office Posters

The following are handouts and office posters that may be used by in-network contract service providers of LifeWays CMH. 

• Bill of Rights 8.5 x 11
• Bill of Rights - Residential - 8.5 x 11
• Code of Responsibilities 8.5 x 11
• Grievance & Appeals Brochure
• HIPAA Brochure
• Member Handbook
• PCP Facilitator Brochure
  Privacy Notice
• Self-Determination Brochure
• The Michigan Whistleblowers Protection Act
• Your Rights When Receiving Mental Health Services