Client Forms & Instructions

Having Problems accessing your addiction treatment benefits? 

Single County Authority (SCA) Funding Request for Authorization Packet

English

  1. Request for Authorization (RFA) - 8/10/21 (DOCX)
  2. Client Rights Notification - 2/27/14 (PDF)
  3. Grievance and Appeal Proccess - 8/22/19 (PDF)
  4. General Consent to Release English - 2/27/14 (PDF)
  5. Consent for Redisclosure English - 2/27/2014 (PDF)
  6. Methadone Maintenance Treatment Agreement - 9/1/13 - Only Applicable to Methadone Providers (PDF)

Spanish

  1. General Consent to Release Spanish - 2/27/14 (PDF)
  2. Consent for Redisclosure Spanish - 2/27/2014 (PDF)

Liability Determination Forms

Wellness Court Forms

  1. Treatment Update Report Form - 3/23/2022 (PDF)

Fiscal Forms

  1. Password Protect File Instructions (PDF)
  2. HDA Form 310 for Inpatient 8-24-2023
  3. HDA Form 310 for Outpatient 8-24-2023
  4. HDA 310 Addendum ~ 8-24-2023
  5. Case Management Invoicing Report W-Instructions (08.14.2023)
  6. HDA Form 311 Cost Reimbursed INVOICE 8-24-2023
  7. HDA Form 311 Prevention Invoice 8-24-2023
  8. Opioid MAT Invoice 5-3-2023

York / Adams Drug & Alcohol Commission Report Forms

  1. York Adams Drug and Alcohol Commission Outcome Measures Form (XLS)