Forms and Manuals
The forms below are provided as Word files for download.
Screening, Triage and Referral Interview and Registration Form (417k doc)
The Guilford Center's Operations Manual - NEW 07.14.10 (2 Mb doc)
Data Submission Instructions (50k PDF)
LME Consumer Admission and Discharge Form - revised 09.04.09 (237k dot)
Instructions for LME Consumer Admission and Discharge Form (120k doc)
Authorization Request Form - REVISED 7-06 (156k dot)
Fee Setting & Insurance Information (80k dot)
The Guilford Center's Sliding Reimbursement Billing Scale FY 09-10
Outpatient Provider Questionnaire (80k dot)
Service Location Registration Form (307k dot)
Person Centered Planning (PCP)
The NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services has published a new PCP format with a one-page consumer profile instead of the current cover page and three interview pages. The Division states, "We are pleased to announce that, beginning March 1, 2010, for all other services requiring a PCP, the new format MAY be used when the next annual re-write of the PCP is due. Beginning July 1, 2010, the new format MUST be used when the next annual re-write of the PCP is due." See Implementation Update #68 for more details http://www.ncdhhs.gov/mhddsas/servicedefinitions/servdefupdates/dmadmh2-2-10update68.pdf.
Note that there is a separate PCP and a separate manual for Psychosocial Rehabilitation (PSR). Below are links to manuals, PCPs and supplemental pages:
PCP Instruction Manual 02.03.2010
PCP 02.03.2010
PCP Update/Revision Supplemental Page 02.03.2010
PCP Update/Revision Signature Supplemental Page 02.03.2010
PCP PSR Instruction Manual 01.29.2010
PCP PCR Version 01.29.2010
Please contact the providerhelpdesk@guilfordcenter.com if you have questions.
IPRS Target Populations, Special Populations Update Form - revised 09.09.09 (138k DOT)
Population Crosswalk
Transition to IPRS Simplification
Domain Descriptors for Revised Target Populations:
AMSRE Stable (32k DOC)
AMI Moderate (33k DOC)
AMI Severe (31k DOC)
CMH Mild (33k DOC)
CMH Moderate (29k DOC)
CMH Severe (31k DOC)
Adult Developmental Disabilities (152k PDF)
Adult Mental Health (204k PDF)
Adult Substance Abuse (228k PDF)
Child Developmental Disability (128k PDF)
Child Mental Health (256k PDF)
Child Substance Abuse (216k PDF)
IPRS Target Populations Details provide information on all effective IPRS Target Populations Groups. All Target Groups are included, along with specific client eligibility criteria, restrictions, valid diagnosis, Utilization Management requirements, funding sources, services supported by the population group, and concurrency rules.
This information is being furnished to help clarify your understanding of target pop groups, their specific requirements and effect on claims.