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The Department of Health and Mental Hygiene

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Local Health Departments and Private Vendors Forms

Forms commonly used by the twenty-four Local Health Departments
Schedule of Charges - DHMH 4411 A & B
LHDSochargeA.pdf
FY 16 Non-Chargeable List
FY 16 Out Patient Services - Ability to Pay Scale
BHA Halfway House, Long Term Care & Residential ICF - Ability to Pay Scale
FY 16 BHA ATPS Instructions
FY 16 Adult Day Care Services - Ability to Pay Scale
Worksheet to be used for Halfway House, Long Term Care & Residential ICF
Forms Commonly used by the Private Vendors
BHA4411aschedule.doc Schedule of Charges - DHMH 4411 A & B
BHA4411aschedule.pdf 
BHA4411bschedule.xls
BHA4411bschedule.pdf 
BHAdefinition4411b.doc
BHAdefinition4411b.pdf
FY 16 Non-Chargeable List
FY 16 Out Patient Services - Ability to Pay Scale
BHA Halfway House, Long Term Care & Residential ICF - Ability to Pay Scale
ADC-AbilitytoPayScheduleFY16 FY 16 Adult Day Care Services - Ability to Pay Scale
Worksheet to be used for Halfway House, Long Term Care & Residential ICF
BHAResWorksheet.pdf
FY 16 BHA ATPS Instructions
BHA-ATPS-InstructionsFY16