APPENDIX A - Reimbursement Forms And Instructions

• Adjustment Request Form (Rev. 1/1/07)
• Adjustment Request Form Instructions (Rev. 1/1/07)
• Definition Of Family Unit For Determining Family Income
• Eligibility Verification Worksheet
• Eligibility Verification Worksheet Instructions
• Extended Payment Contract (Rev. 1/1/07)
• Instructions for Completing the Extended Payment Contract (Rev. 1/1/07)
• Fee Appeal Form (Rev. 1/1/07)
• Instructions For Completing Fee Appeal Form (Rev. 1/1/07)
• Fee Schedule (Rev. 07/01/05)
• Fee Subsidy Scale (Rev. 05/01/06)
• Financial Contract Instructions
• Financial Contract Worksheet (Rev. 07/02)                       
• Financial Contract (Rev. 4/30/04) 
• Medicaid Denial Worksheet Instructions
• Medicaid Denial Worksheets  (Rev. 10/1/01)                    
• Medicaid Denial Logsheet  (Rev. 2/1/02)  
• MH Case Management Monthly Follow-Up Worksheet
• Instructions for Completing CM Monthly Follow-Up Worksheet
• Procedures for Following-up on Medicaid Denials
• Reimbursement Matrix (Rev. 07/02)
• Third Party Denial Instructions
• Third Party Denial Logsheet (Rev. 2/1/02)
• Third Party Denial Worksheet (Rev. 2/1/02)                     

APPENDIX B - Reimbursement Memoranda

• 2003-001-Adjustment Request Form
• 2003-002-Financial Contract and Financial Due Report
• 2003-003-Medicare Coverage and Co-payments
• 2003-004-Sentara and HKPlus Commercial Coverage for SA Services
• 2003-005-Southern Health/CareNet Medicaid HMO
• 2004-001-Medicaid Coverage - FAMIS and SLH
• 2004-002 - MH Case Management/Medicaid Billing Monthly Verification
• 2006-001 - Fee Subsidy Scale
• 2007-001 - Revised Reimbursement Forms
• 2008-001 - Medicaid Substance Abuse Fund Sources
• 2008-002 - Medicare HMO's
• 2008-003 - Substance Abuse Case Management and Substance Abuse Crisis
• 2008-04 - Financials For Consumers “In Jail” and “Released from Jail”