Calvert County Health Department

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Calvert County Local Behavioral Health Authority

Forms for Requests for Services

Buprenorphine Initiative
This grant aims to help increase awareness of the importance of effective treatment for behavioral health disorders within Calvert County and to provide MOUD medications to those who qualify. Prescribing MOUD providers may submit a request for uninsured or underinsured clients unable to afford their Buprenorphine medication. Providers can access the application by clicking on the link below and sending the finalized copy to Jayla Jones at:
mdh-dl-calchd-coreservicescchd@maryland.gov

Buprenorphine Initiative Funding Request Form

Hub and Spoke Program
This program aims to expand the number of MOUD providers while increasing the number of treated individuals. MOUD providers can refer any clients diagnosed with an opioid use disorder to the program. Eligible individuals will be enrolled in a continuum of care, where they’ll be provided with case management services to ensure all of their needs are met. Upon completion, referrals can be sent to Jayla Jones at: mdh-dl-calchd-coreservicescchd@maryland.gov

Hub and Spoke Program Referral Form

Client Support Services Request Form
The purpose of these funds is to assist individuals struggling with mental health disorders and/or substance use disorders to receive necessary support services when all other resources have been denied. Funding helps assist individuals with an array of services including pharmacy, transportation, employment services, vital records, medical/dental services, and other unmet needs as expressed by the service recipient and/or identified by the behavioral health professional. To qualify, the behavioral health professional must fill out the request and attach a receipt of purchase and/or invoice in order to be reimbursed. Applications must also include a Release of Information, Treatment Plan, letter from provider to confirm treatment, and a sustainability plan, if applicable. All requests for individuals with a Substance Use Disorder must go through Syreeta Clark, the State Care Coordinator, as the recipient must be enrolled in State Care Coordination to qualify.

Child & Adolescent Consumer Support Services Request Form

Adult Consumer Support Services Request Form

Budget Chart for CSF Application:
Download in Excel
Download as PDF

Residential Rehabilitation Program Forms
Residential Rehabilitation Program (RRP) provides housing and supportive services to single individuals. The goal of residential rehabilitation is to provide services that will support an individual to transition to independent housing of their choice. Residential Rehabilitation Programs provide staff support around areas of personal needs such as medication monitoring, independent living skills, symptom management, stress management, relapse prevention planning with linkages to employment, education and/or vocational services, crisis prevention and other services that will help with the individual’s recovery.

BHA Residential Rehabilitation Program Application Form Instructions

Residential Rehabilitation Program Managed Intervention Plan (Mip)

RRP Certificate of Approval

Residential Rehabilitation Program Level of Care Change Form

Residential Rehabilitation Program Discharge Information Form

 

Financial Reporting Forms for All Sub-Vendors Including 440, 437, 438, and Direct Deposit Authorization for Vendors

Instructions for Completion of the Interim Report

Interim Report of Actual Expenses, Receipts and Performance Measures

Instructions for Completion of the Human Service Agreement Request for Payment

Human Service Agreement Request for Payment - Vendor Invoice

Direct Deposit Authorization for Vendor Payments

440, 440a Reporting Forms and Instructions

Human Service Agreements Annual Report