These forms are for DMH Directly Operated Employees
~ Face Sheets/Billing Forms ~

Procedures for Forms

• Integrated System Access
  
  Applications Access Form Instructions rev. 6/06
  Applications Access Form rev. 6/06 SAMPLE
  Applications Access Form Attachment
  Applications Access Form Codes
  Integrated System Access Roles rev. 01/10/07
  Authorization to Sign CIOB Access Forms rev. 3/06 SAMPLE
  DMH Policy 302.18 on "Security and Integrity of the Department's IS"
  Confidentiality Oath ~ SAMPLE
  SecurID Renewal County and AUP~ Sample Form and Sample AUP
  Downey Data Center County rev. 7/07
  Downey Data Center County ~ SAMPLE
  Request to Change Funding Source on COS

• Service Delivery Staff
  
  Rendering Provider Form rev. 3/14
  Rendering Provider Form Attachment rev. 3/14
  Rendering Provider Form Instructions rev. 3/19
  Rendering Provider DMH SAMPLE rev. 3/14
  Rendering Provider NPI Updates Sample
  Taxonomy Codes and Descriptions
  
  Rendering Provider Termination Form Instructions
  Sample Term IS290
  Rendering Prov Termination Sample
  
  
• Billing Provider
  
  Request to Update Provider Information ~ Form
  Request to Update Provider Information ~ Instructions

Click here to go to DMH HIPAA-related Privacy Forms