MULTNOMAH COUNTY OREGON
               DEPARTMENT OF COUNTY HUMAN SERVICES. Mental Health And Addiction Services Division
                421 SW Oak Street, Suite 520, Portland, Oregon 97204, Phone (503) 988-5464, Fax (503) 988-3575

                      MULTNOMAH TREATMENT FUND

Multnomah Treatment Fund is a safety net program for Multnomah County indigent citizens who do not
qualify for OHP (Medicaid) due to income restrictions. Multnomah Treatment Fund may also be used as
a funding source while individuals are waiting for, or reinstating OHP coverage.

PLEASE NOTE: These instructions apply to those qualifying MTF adults and children being served in
general or school-aged outpatient or adult SMI level services only.

Criteria for Initial Authorization:
        1. Financial: An individual is financially eligible for services funded by MTF if his/her
            family’s income is at or below 200% of the current federal poverty level and they lack
            insurance or other resources to pay for services.

                                        Based on 2011 Federal Poverty Guidelines
          Number in Family                                      Monthly Gross Income is less than:
          1                                                     $1815
          2                                                     $2451
          3                                                     $3088
          4                                                     $3725
          5                                                     $4361
          6                                                     $4998
          7                                                     $5635
          8                                                     $6272

        2. Clinical: Client meets the Priority 1 clinical criteria* as outlined in ORS 430.675, which may
        include a diagnosis of severe mental health disorder (psychotic spectrum disorders, bipolar or
        severe major depressive disorders); and

        *Priority 1 is defined as those persons who, in accordance with the assessment of
        professionals in the field of mental health, are at immediate risk of hospitalization for the
        treatment of mental or emotional disorders, or are in need of continuing services to avoid
        hospitalization, or pose a hazard to the health and safety of others.

        Client is at high risk as evidenced by recent discharge from a psychiatric acute care facility or
        from incarceration, or if an adult, in jeopardy of losing custody of children, or if a child, in
        jeopardy of being removed from their home all due to severe mental illness.

Criteria for Re-authorization:
        1. Financial: same as above.

        2. Clinical:

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                a. Client continues to meet a diagnosis of severe mental health disorder (psychotic
                spectrum disorders, bipolar or severe major depressive disorders; and
                b. Client is currently prescribed Clozaril or intramuscular medication for his/her
                psychiatric disorder; or
                c. Client has a HAP Shelter-Plus Voucher
                d. If client does not meet Priority 1 clinical criteria, provider has demonstrated attempts
                to locate non-MTF funded community-based treatment service and has not been
                successful and there is a strong possibility that the client will significantly decompensate
                without ongoing treatment services.

Additional Processes & Expectations:
       1. Every provider working with clients funded by MTF is required to assist clients in applying
       for insurance coverage and/or other resources as soon as possible. Please note, that clients who
       meet criteria for MTF qualify for the Indigent Medications program (please see below for more

        2. For individuals who are Medicare beneficiaries, providers will be required to attempt to locate
        providers who accept Medicare and/or bill Medicare first. MTF will be approved only for co-
        pays and payment for services not covered by Medicare benefits.

        3. Mental Health Assessments and Treatment Plans do not need to be submitted when requesting
        MTF authorization/reauthorization. However, the Mental Health and Addiction Services
        Division (MHASD) expect this documentation to be completed and current for ongoing quality
        assurance and is subject to audit.

Multnomah Treatment Fund Authorization Request Steps:
      The referenced forms below can be located at the Multnomah County Mental Health and
      Addiction Services Provider webpage:

                STEP 1 Agency clinician screens for financial and clinical criteria as outlined above.

                STEP 2 For Initial Authorization or Re-authorization: the agency will complete and
                submit a 1 page Adult/Child Authorization Request and Attestation Form.

                STEP 3 Fax completed Adult/Child Authorization Request and Attestation Form to:
                (503)-988-3575. Multnomah County will initiate an authorization in CIM. Adults may
                be authorized up to 12 months, children up to 6 months. It is essential that this form is
                complete or it will be returned for completion of data elements before the authorization
                is approved.

Multnomah County Contracted Mental Health Providers may request up to a 60 day supply of psychiatric
medications for consumers who meet the above clinical and financial MTF criteria. It is not required to
have an outpatient authorization in place in order for providers to request Indigent Medications.

Providers should complete the steps below in order to request medications for eligible consumers. All
referenced forms can be located at the Multnomah County Mental Health and Addictions Services
Provider webpage:

                STEP 1 Agency's prescriber fills out the Indigent Client Pharmacy Log and faxes the
                Indigent Client Pharmacy Log to the Multnomah County Community Mental Health at
                fax # (503)-988-3575 Mental Health clinical and financial forms do not need to be
                submitted, however, the Mental Health and Addiction Services Division (MHASD)
                expects this documentation to be completed and current for ongoing quality assurance

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               and is subject to audit. Multnomah County Community Mental Health will authorize up
               to 60 days of medication during a 6 month time period.

               STEP 2 Fax the Indigent Client Pharmacy Log to one of the Multnomah County
               Contracted Pharmacies listed below:

     Brooklyn Pharmacy, Inc.                             Payless Drugs
     Contact person: Mike Dardis                         Contact person: Kim Schneiderman
     3131 SE Milwaukie                                   PO Box 230969
     Portland, OR 97202                                  Portland, OR 97281
     Phone: 503-234-3488                                 Phone: 503-372-1750
     Fax: 503.235-0373                                   Fax: 503-372-1792
     ID #93-0498369                                      ID #94-3382598
     Hi-School Pharmacy/PMC                              Gateway Medical Pharmacy
     Contact person: Phil Pasch                          Contact person: Lynn Virtue
     501 SW 10th Ave.                                    1125 NE 99th Ave.
     Portland, OR 97205                                  Portland, OR 97220
     Phone: 503-226.6644                                 Phone: 503-254-7383
     Fax: 503-226-2908                                   Fax: 503-254-4568
     ID #91-1504881                                      ID #93-1244084

               STEP 3 The pharmacy will then fill up to 30 days of medication at a time. The
               consumer will then have refills available until the 60 days has been exhausted. The
               pharmacy will invoice the county according to their contract.

               STEP 4 During this 60 day period it is expected that the agency will make every attempt
               to obtain either outside prescription assistance or eligibility under the Oregon Health
               Plan for the authorized consumer. Websites that might be helpful for prescription
               assistance programs are: or Please note: the
               process for obtaining prescription assistance can take up to 2 months or more, so it is
               necessary to get started on these applications as soon as you apply for the IM program.

        In relation to any prescribed psychiatric medications through the IM program, reimbursements
        for lab draws are also covered. Agencies will order and pay for labs from a provider who
        provides this service to them before requesting reimbursement from the County. To request
        reimbursement, providers shall submit an invoice with proof of payment to the address below
        within 90 days from date of service:

                       Multnomah County MHASD
                       Attn. Business Services
                       421 SW Oak St. Suite 520
                       Portland, OR 97204

Questions: MTF Coordinator Sonja G Miller MA NCC LPC 503-988-3999 x 24443

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