CMHPSM Organizational Service Provider Forms
Organizational Forms
Forms for various organizational provider submission requirements are found on this page.
SUD Treatment Service Provider Forms
Forms should be submitted directly to Lenawee CMH, Livingston CMH, or the CMHPSM for Monroe and Washtenaw SUD treatment service contracts.
SUD Treatment Provider Debarment
SUD Treatment Provider Credentialing Forms
Submitted to CMHPSM for Monroe and Washtenaw SUD treatment service contracts held by the CMHPSM for SUD treatment provider organizations. These forms are used for SUD treatment provider organizational credentialing and re-credentialing activities.
Instructions:
Credentialing Application Instructions
Forms:
Main SUD Treatment Provider Credentialing Application (Word)
Employee Credentialing Information Attachment A
Employee Background Check Information Attachment B
Employee Training Information Attachment C
Debarment Information Attachment D
SUD Treatment Provider Finance Related Forms
Submitted directly to CMHPSM for Monroe and Washtenaw SUD treatment service contracts.
CMHPSM Financial Audit Submission Form (Online Form)
CMHPSM Financial Audit Waiver Request Form (Online Form)
Mental Health / IDD Service Provider Forms
While these forms are hosted on the CMHPSM website they should be submitted to one of our partner CMHSPs (Lenawee CMH, Livingston CMH, Monroe CMH, or Washtenaw County CMH).
MH / IDD Service Provider Debarment Information Forms
MH / IDD Service Provider Organizational Credentialing / Re-Credentialing Forms
Instructions:
Organizational Credentialing Application Instructions
Forms:
Main MH/IDD Credentialing & Recredentialing Application Form (Word)
Attachment A: Administrative Staff Requirements (Word)
Attachment A: Administrative Staff Requirements (Excel)
Attachment B: Aide Level / DSP Staff Background Check Form (Word)
Attachment B: Aide Level / DSP Staff Background Check Form (Excel)
Attachment C: Aide Level / DSP Staff Training Requirements Form (Word)
Attachment C: Aide Level / DSP Staff Training Requirements Form (Excel)
Attachment D: Licensed Staff Background Check Form (Word)
Attachment D: Licensed Staff Background Check Form (Excel)
Attachment E: Licensed Staff Training Requirements Form (Word)
Attachment E: Licensed Staff Training Requirements Form (Excel)
Attachment F: Licensed Staff Credentialing Information Form (Word)
Attachment F: Licensed Staff Credentialing Information Form (Excel)
Mental Health / IDD Service Provider Finance
While these forms are hosted on the CMHPSM website they should be submitted to one of our partner CMHSPs (Lenawee CMH, Livingston CMH, Monroe CMH, or Washtenaw County CMH).
Form: