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Forms & Applications

Results in category 'Children's Mental Health'

Application Instructions for Interstate Endorsement in Montana
Authorization Request Form (Therapeutic Home Visit)
Certificate of Need (Acute Inpatient Hospital/ PTRF/ PTRF-AS)
Certificate of Need (PTRF Waiver Program)
Certificate of Need (Partial Hospital Program)
Certificate of Need (Therapeutic Family Care)
Certificate of Need (Therapeutic Group Home)
Continued Stay Authorization Request Form (PRTF)
Continued Stay Authorization Request Form (Partial Hospital)
Continued Stay Authorization Request Form (Therapeutic Family Care)
Continued Stay Authorization Request Form (Therapeutic Group Home)
Correction to Youth Information Form
Discharge Notification Form
In-State PRTF Denial Letter
Interstate Compact Form
Level of Care Re-determination Request Form (PRTF Waiver Program)
MT Medicaid Youth Extraordinary Needs Aide (ENA) Services Request Form (TGH)
Non Medicaid Services (SSP/SOCA) Provider Monthly Report
PRTF Waiver Referral Form
PTRF Discharge Plan Review Form
Prior Authorization Request Form (Acute Inpatient Hospital)
Prior Authorization Request Form (Day Treatment PRTF Waiver Request Form)
Prior Authorization Request Form (PRTF)
Prior Authorization Request Form (Partial Hospital Program)
Prior Authorization Request Form (Therapeutic Family Care)
Prior Authorization Request Form (Therapeutic Group Home)
Prior Authorization/Continued Stay Request Form (Outpatient in excess of 24 sessions)
State of MT Department of Public Health and Human Services Notification and Authorization Request Form (Therapeutic Home Visit) PRTF
State of MT Department of Public Health and Human Services Notification and Authorization Request Form (Therapeutic Home Visit) TGH
Supplemental Services Program (SSP) Attestation
Supplemental Services Program - System of Care Account (SSP-SOCA) Application
Team Enrollment/Re-Enrollment Form
Therapeutic Group Home Initial Stay Payment Authorization Request
Transition Work Group Case Presentation Form

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