Provider Forms
The Sandhills Center Utilization Management and Network Operations departments want to assist our affiliated care providers as much as possible. Listed below are helpful provider forms you can access and use.
Utilization Management
- Special announcement: Effective May 11, 2023, the clinical policy flexibilities that were instituted as part of the federal Public Health Emergency will end. This includes flexibilities for authorizations, staffing ratios, sites of service, training requirements and others. For more information, please see Special Bulleting #265 - PDF. Please note that this does not apply to Innovations Appendix K flexibilities. Appendix K flexibilities will end Nov. 11, 2023.
- Sandhills Center JIVA authorization system training - Video Link
- Logging in to Jiva- PDF
- Submitting an Initial Behavioral Health Outpatient Request - PDF
- Submitting an Initial Physical Health Inpatient Request - PDF
- Submitting an Initial Behavioral Health Inpatient Request - for use by Psychiatric Hospitals/Units and Alcohol Drug Abuse Treatment Centers (ADATCs) only - PDF
- All Service Codes to be Used on Authorization Requests in Jiva - PDF
Network Operations
- Provider Contract Information Form - PDF
- Disputes Resolution Flowchart - PDF
- Sandhills Center Dispute Resolution Form - PDF
- Notice of Change Request - PDF
Network Provider Monitoring Process
- Opioid Treatment Assessment Tool - PDF
- Suicide Prevention Assessment Monitoring Tool - PDF
- PTSD Assessment Monitoring Tool - PDF
- Bipolar Disorder Assessment Monitoring Tool - PDF
- Autism Spectrum Disorders Assessment Monitoring Tool - PDF
- ADHD Assessment Monitoring Tool - PDF
- Major Depressive Disorder Monitoring Tool - Clinical Self-Report Instructions - PDF
- Major Depressive Disorder Monitoring Tool -- Clinical Self-Report - PDF
- Major Depressive Disorder Monitoring Tool - PDF
- Network Provider Monitoring with Tools and Training Presentations DHHS - PDF
- NCDHHS: Provider Monitoring
- Alcohol and Other Drug Use Disorder Monitoring Tool - PDF
- Alcohol and Other Drug Dependence Clinical Monitoring Tool Instructions - PDF
- Alcohol and Other Drug Dependence Clinical Monitoring Self Report Tool - PDF
Additional forms and information are added when appropriate.
If you have questions, contact ProviderHelpDesk@SandhillsCenter.org, or call 1-855-777-4652. You may also visit the Provider Support Portal.
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