These forms are for Outpatient Fee-For-Service Providers

Procedures for Forms

Use the DDE/EDI Application Processing Checklist to find the forms you need...

• 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
  DMH Policy 302.18 on "Security and Integrity of the Department's IS"
  Confidentiality Oath
  Downey Data Center Registration/Non-County rev. 11/07
  Downey Data Center Registration/Non-County ~ SAMPLE
  IS Connection Options
  
  SecurID Renewal Non County and AUP and Sample Form and Sample AUP

• Service Delivery Staff
  
  Rendering Provider Form rev. 3/14
  Rendering Provider Form Attachment rev. 3/07
  Rendering Provider FFS Sample rev. 3/14
  Rendering Provider Form Instructions rev. 3/19
  Rendering Provider License Update Sample
  Taxonomy Codes and Descriptions

• Secure File Transfer Forms

  Trading Partner Agreement
  Trading Partner Agent Authorization Agreement
  Digital Certification Request Form
  DDE/EDI Agreement Form

  EDI/SFT Submission Incident Report