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Addictive & Mental Disorders Division

Forms and Applications

Medicaid Enrollment Application form for WASP and MHSP

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Clinical Eligibility Form for WASP and MHSP

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Applicant Checklist for WASP and MHSP

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72-Hr Crisis Stabilization Form

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Crisis Intervention and Response Form

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Substance Use Disorder (SUD) Prior Authorization Request Form for Residential and Inpatient Services
Substance Use Disorder (SUD) Continued Stay Request Form for Residential and Inpatient Services

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