Tools & Assessments

Included in this section are forms and tools to help you perform some of your functions as a provider agency.

Authorization and Service Request Forms

(Does not include those available in AlphaMCS)

pdf-1  Psychological Testing Authorization Request Form

pdf-1  Regional Assessment and Referral Form (RARF)

pdf-1  N.C. DHHS Regional Referral Form

pdf-1  Worksheet for Requesting Exceptions to the Diversion Law (SB859)


Incident Reporting

 NC Incident Response and Improvement System (IRIS)

pdf-1  QM-02 Incident Report Form – November 2014

word_doc   QM-11 Quarterly Level 1 Provider Report – November 2014


Level of Care Tools

pdf-1   Child Mental Health – CALOCUS Scoresheet

pdf-1   Adult Mental Health – LOCUS Scoresheet

pdf-1   Child/Adolescent Substance Use – ASAM Worksheet for Adolescents

pdf-1   Adult Substance Use – ASAM Worksheet for Adults

pdf-1   North Carolina Support Needs Assessment Profile (NC-SNAP) – NC-SNAP


Claims & Finance

excel   AlphaMCS CSV RA Conversion Template

pdf-1  Guidance on Using the AlphaMCS Claims Dump File

pdf-1  Out of State Travel Form

excel   Provider Self-Audit Payback Form

pdf-1  Self-Audit Protocol

word_doc   Vaya Health High Volume Claim Inquiry

pdf-1  Vaya Health Electronic Funds Transfer (EFT) Authorization Form


Planning Forms

NC DHHS Person Centered Planning

pdf-1  North Carolina Department of Health and Human Services Division of Mental Health, Developmental Disabilities, and Substance Abuse Services Person-Centered Planning Instruction Manual (2010 version)

pdf-1  Short Range Goal Template for Innovations Providers

excel   Crisis Intervention and Prevention Plan

pdf-1  Vaya Comprehensive Clinical Assessment (10/2017)

Call 1-800-849-6127 toll free 24/7 to access mental health, substance use and intellectual and/or developmental disability services. Members can request materials in Spanish or English.

Llamar al número gratuito 1-800-849-6127 24/7 para obtener servicios y apoyo a la salud mental, discapacidades de desarrollo y abuso de sustancias. Los miembros pueden solicitar materiales en español o Inglés.