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York / Adams Drug & Alcohol Commission
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Client Forms & Instructions
Having Problems accessing your addiction treatment benefits?
Information on
Act 106 (PDF)
Single County Authority (SCA) Funding Request for Authorization Packet
English
Request for Authorization (RFA) - 8/10/21 (DOCX)
Client Rights Notification - 2/27/14 (PDF)
Grievance and Appeal Proccess - 8/22/19 (PDF)
General Consent to Release English - 2/27/14 (PDF)
Consent for Redisclosure English - 2/27/2014 (PDF)
Methadone Maintenance Treatment Agreement - 9/1/13 - Only Applicable to Methadone Providers (PDF)
Spanish
General Consent to Release Spanish - 2/27/14 (PDF)
Consent for Redisclosure Spanish - 2/27/2014 (PDF)
Liability Determination Forms
Liability Determination Form - 8/1/2018 (PDF)
Request for Liability Reduction - 7/2/14 (PDF)
Liability Determination Tables -
Department of Drug and Alcohol Programs (DDAP) website
Wellness Court Forms
Treatment Update Report Form - 3/23/2022 (PDF)
Fiscal Forms
Password Protect File Instructions (PDF)
HDA Form 310 for Inpatient 8-24-2023
HDA Form 310 for Outpatient 8-24-2023
HDA 310 Addendum ~ 8-24-2023
Case Management Invoicing Report W-Instructions (08.14.2023)
HDA Form 311 Cost Reimbursed INVOICE 8-24-2023
HDA Form 311 Prevention Invoice 8-24-2023
Opioid MAT Invoice 5-3-2023
York / Adams Drug & Alcohol Commission Report Forms
York Adams Drug and Alcohol Commission Outcome Measures Form (XLS)
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