Mid-South Substance Abuse Commission

Quality Forms

42 C.F.R. HIPAA MSSAC Provider Guidelines

Advance Directive Guidelines 

Authorization and Consent for Release of Confidential Information-Standard now on Policies 2009 page, Policy T003

Authorization and Consent for the Release of Confidential Information-Substance Abuse System Referral 

Authorization and Consent for the Release of Confidential Information-Medicaid 

Authorization and Consent for the Release of Confidential Information-Non Medicaid  

Capacity Wait List Form 

CareNet Forms Necessary in Client Files

Client Notice of Confidentiality

Confirmation of Quality and Training Form

Client Satisfaction Surveys FY09/10 (below) 

Click on program below for your survey forms.

Arbor Circle   Addiction Solutions    Allegiance Addiction Recovery Center   Allegiance Substance Abuse Services    Birchtree Cottage  CEI-CATS Program   CEI-Clinton Co. Counseling Center    Child & Family Services    Clearview    Cristo Rey    Eaton Substance Abuse Program    FSCA Adrian    FSCA Born Free     House of Commons   ICHD-McMathis    ICHD-Northpointe    ICHD-Two Rivers    Insight Recovery Center    Kairos    McCullough Vargas-Adrian    McCullough Vargas-Hillsdale   `NCA-Glass House    NCA-Holden House    NCA/LRA      Proaction Life Guidance    Proaction Men's    Proaction Women's    Proaction Hispanic    Victory Clinic Jackson    Victory Clinic Lansing  

Client Satisfaction Survey Waiver Form 

Consumer Handbook Request Form 2009  

Criminal Justice System Referral Form

Critical Incidents-Sentinel Events Data Report Form 

Critical Incidents-Sentinel Events Guide

Critical Incidents-Sentinel Events Root Cause Analysis Plan Of Correction Form FY0708

Discharge Outcome Survey 

Discharge Report Form 

Discharge Report Instructions

Guidelines for Grievance & Appeal

LEP Training Log 

LEP Interpreter Log Sheet 

Member Services  

New Employee Verification Form 

Outcome Survey Instructions 

Outcome Survey Waiver 

Outstanding PIHP Performance Indicator Report

Notices of Denial, Hearing Rights, and Suspension, Reduction or Termination can now be found on Policies 2009 page, Policy Q003

Performance Indicator Report

PIHP PI Report Memo 

PIHP PI Report Instructions 

Instructions Attachment A    Instructions Attachment B    Instructions Attachment C    Instructions Attachment D    Instructions Attachment E    Instructions Attachment F    Instructions Attachment G    Instructions Attachment H: PIHP PI Report                   

Priority Population Waiting List Deficiencies Report Form 

Priority Population Waiting List Deficiencies Guidelines

Mid-South Substance Abuse Commission Service Provider List 

Risk based Provider Monitoring Plan 

Risk based Provider Monitoring Tool  

State Sentinel Guide for Programs

Transfer of Clients for Continuum of Care Memo

Transfer of Clients for Continuum of Care Procedure

Walk Through Form for Providers 

QUALIFICATIONS/CREDENTIALING INFORMATION

History of SA Specialist and Practitioner

MDCH Approved Specialist vs Practitioner

Credentialing Summary Table

RECIPIENT RIGHTS

English Know Your Rights Brochure 

Spanish Know Your Rights Brochure  

Recipient Rights Services Poster Pg. 1 

Recipient Rights Services Poster Pg. 2 

Spanish Recipient Rights Poster Pg. 1 

Spanish Recipient Rights Poster Pg. 2 

Know Your Rights

Individual forms now on Policies 2009 page, Policy A007

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2875 Northwind Drive * Suite. 215 * East Lansing, Michigan * 48823