To be completed during the first face-to-face meeting when it is by 04Q4eg8s


									                                                        Enrollee Registration Form (ERF)
To be completed during the first face-to-face meeting, when it is determined that the consumer will be receiving services with this
provider. Use this form to register consumers with Western Highlands Network (WHN). This form allows for the release of information
regarding eligibility for services for Medicaid/IPRS consumers and must be submitted to WHN in order to bill for their services. The
ERF does not constitute consent for treatment, which must be obtained by the new provider before services are delivered.

                           Clinical Home Assignment                                      Request for Medicaid/Health Choice Referral Number
Check this box if you are the only provider serving this individual,         3.
                                                                                  Check this box if you are requesting a WHN referral number and did not receive
or providing an enhanced service to this individual, or have chosen               a referral number from a Carolina Access enrolled physician or psychiatrist.
to be the primary clinical home for this individual when there are
two or more providers.                                                              I request a referral number to see a Medicaid or Health Choice
                                                                                       consumer under 21 years old for outpatient therapy.
 1. Please register me as the Clinical Home for this
             individual.                                                     4.
                                                                                  This individual meets medical necessity criteria:  Yes /  No
 Registration only

                                             PLEASE TYPE OR LEGIBLY PRINT INFORMATION
     ____________________________             ___________________________                   ___________          ______________________________________
      Consumer’s Legal Last Name                   Legal First Name                         Middle Initial       Maiden Name (Required for female consumers)
6.                                     7.                             8.                                                 9.
     _____ / _____ / _____                   M    OR        F              ___________ - ______ - __________                  ______________________________
        Date of Birth                            Sex                               Social Security #                            Medicaid # or Health Choice #
10.                                                          11.                                                                 12.
      ______________________________________                       ______________________________________                              ________________________
              County of Residence                                    If Medicaid, county of Medicaid Eligibility                       WHN Consumer # (if known)

I, __________________________________________________ request that my services/supports be provided by:
             Consumer (or Guardian if consumer is less than 18 years old)
_____________________________________________________________                                                  WHN Provider ID #: _______________
             New Provider/Agency Name (please print)                                                                             (Example: 36xxx)

16.                                                             17.
      Provider Phone: __________________________                  Provider E-mail Address: ___________________________________________
                                                                (WHN consumer ID # and/or Referral # will be emailed to you for billing purposes.)

                                                    Authorization of Release
CONSUMER: I hereby authorize Western Highlands Network to disclose/release/share information with the provider listed above
including alcohol and/or drug abuse information according to Federal regulations (42 CFA Part 2) and/or information regarding
communicable diseases, in addition to the names of previous treatment agencies. I hereby authorize Western Highlands Network to
advise my previous provider with information from and/or a copy of this form. This form does not constitute Consent for Release
of information from the records of other providers.

I understand that this form does not prohibit me from changing providers through Western Highlands Network in the future.
      _________________________________________________________________________________                                                 ___________________
       Consumer Signature (or Guardian if consumer is under 18 years old; not required for Health Choice consumers)                            Date

      _________________________________________________________________________________                                                 ___________________
      Clinician Signature and title (print and sign)                                                                                            Date

Fax to:                                                                                              Mail to:
A) 828-225-2797 to receive WHN client ID and to access CCIS.                                         Western Highlands Network - Access/UM
B) If unable to enter into CCIS, fax ERF with STR/DCCI/LCAD                                          356 Biltmore Avenue
   forms to 828-225-2782.                                                                            Asheville, NC 28801

                                                                                                                                   Revised: ERF – 3/16/12 WHN

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