Having Problems accessing your addiction treatment benefits?
Information on Act 106: Link to fileDownload
DDAP Assessment |
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| Title | Sixe (Kb) | Link to File |
SCA Funding Request for Authorization Packet |
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| 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 |
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| In-patient - Work in Progress | Download |
| Out-patient - Work in Progress | Download |
Liability Determination Forms |
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| 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 |
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| Title | Size (Kb) | |
| Treatment Update Report Form - 3/23/2022 | 53 | Download |
Fiscal Forms |
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| 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 |
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YADAC Report Forms |
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| Title | Size (Kb) | |
| YADAC Outcome Measures Form | 551 | Download |