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Need Services? Call CenterPoint ACCESS 24/7 at 1-888-581-9988
Accessing Crisis Services

FAQ

Provider Network

Mercer Readiness Reviews

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Forms & Applications


Various Provider Forms:

Provider Payment Form for Community-Based Services

Emergency Department Services (Out of Catchment) and/or In-Patient Services (Out of Catchment AND Out of Network) Provider Enrollment/Medicaid Reimbursement Form

Fax Request to Use CenterPoint NPI

LOCUS Worksheet

CALOCUS worksheet

I/DD Registry of Unmet Needs Referral Form

Murdoch Center Application

LOC Determination Form

LOC Medical Assessment


Involuntary Commitment Forms

DMH 5-72-09 Form-Necessity for Involuntary Commitment

Involuntary Commitment

Emergency Certificate

Invol Comm Petition Form

Invol Eval Form

Custody Order Form


Consumers:

Consumer Request for Access to Medical Record

Release of Information From Medical Record

Worksheet for Requesting Exceptions To The Diversion Law (SB 859)

Incident and Death Report

Restrictive Intervention Detail

Provider Quarterly Incident Report


Provider Medicaid Enrollment:

Enrollment Information


Contracting:

Electronic Funds Transfer Authorization

CenterPoint - Trading Partner Agreement

APSM Manuals

Division Manuals & Forms

Change of Address Form

Workers Compensation Insurance and Automobile Insurance Affidavit

W-9 Request for Taxpayer Identification Number and Certification Form


Provider Monitoring:

AFL Health and Safety Review

Service Specific Endorsement Check Sheets

Monitoring Tool

Frequency and Extent of Monitoring Tool

APSM Manuals


CenterPoint manages MH/DD/SA Services in Forsyth, Stokes, Davie and Rockingham Counties. CenterPoint is URAC accredited in Health Network, Health Call Center and Health Utilization Management - click here to visit the URAC website.

Main Office: 336-714-9100    4045 University Parkway    Winston-Salem, NC 27106

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