Provider Forms



NEW FORMS FOR 2017

For forms related to changes going into effect on January 1, 2017, please go to the Business System 2017 page.


 

Provider Information Updates

  • Provider Application and Information Update
    Use this form to provide updated business and service information.
  • Service Location Information
    Use this form to add a location and to provide updated information for locations already in our network.
  • Practitioner Information
    Use this form to provide practitioner information when submitting a Provider Application and Information Update form, in addition to or instead of completing the Practitioner Information section of that form. Also use this form when submitting a Service Location Information form that is not attached to a Provider Application and Information Update form.
Behavioral Health Initial Treatment Plan
This form should be sent to the member's care manager upon completion. Progress reports on this plan must be sent to care manager quarterly.

Checklist for All Adult Family Home (AFH) and 5-8 Bed Community Based Residential Facility (CBRF) Care Management Visits 
This form is completed by care managers at the time of member reviews.

Prevocational Services Six-Month Status and Progress Report 
To be completed by the authorized prevocational services provider. This report is due to the member's care manager at two points in each calendar year:

  1. Two weeks before the member's annual Member-Centered Plan renewal date
  2. Two weeks before the member's Member-Centered Plan six-month review date

Residential Assessment Form
This form is completed by ContinuUs providers who have new ContinuUs enrollees that already reside in their non-nursing home residential setting at the time of the member's enrollment with ContinuUs. Residential Rate Setting Assessment Tutorial for Providers

Unintended Events Report Form 
All individuals or entities providing services to ContinuUs members are required to report unintended member incidents and events to the Care Management Team within 24 hours from the time the provider becomes aware of the incident/situation. See Member Incidents section in the ContinuUs Provider Handbook for more information.

Provider Comment Form
To comment about a provider that you feel has gone above and beyond in service provision, please complete a Provider Comment Form. Then print the form and mail or fax it to the address on the form. This form can also be used to alert us if you have quality or other concerns relating to a specific provider. The forms are submitted to ContinuUs Provider Services staff for processing and follow-up.

W-9 Form (Request for Taxpayer Identification Number)
Click the link above to go to the IRS site for the W-9 form. You can fill this form out on your computer, and then print and mail or fax it to us. Adult Family Home and CBRF providers must also complete the Adult Family Home/CBRF Additional Tax Information Form.

Provider Succession Plan
Adult Family Home (AFH), CBRF, and Supportive Home Care providers are required to have a succession plan on file with ContinuUs. It is essential that you have a plan to keep residents safe and employees secure, if you were temporarily (or permanently) unable to return to operate your business. This form provides ContinuUs with information we need to work with your “successor” if this should occur. Please submit a new form if your information changes.

Also see these pages for relevant forms:

Provider Portal

Claims and Billing Information

Provider Application and Contracting