Registration/Attestation Form
To be Used by Personalized Recovery Oriented Services (PROS) Programs
Date ____/____/_____
| Recipient Information | Provider Information |
|---|---|
| Name: | Name: |
| Date of Birth: | Address: |
| Gender: M or F | Provider ID: |
| Social Security Number: | Locator Code: |
| Have a Medicaid Number? Yes or No | New Registration: Yes or No |
| If Yes, Medicaid #: | Update Medicaid: Status Yes or No |
| If known, what is the County of Medicaid Responsibility: | Update Component Registration: Yes or No |
Registration - Please Select One Option
Please Note: Registration in a PROS does not effect Intensive Case Management (ICM), Supportive Case Management (SCM), Blended Case Management (BCM), or residential services
Community Rehabilitation and
Support (CRS), Intensive Rehabilitation (IR), Ongoing Rehabilitation and Support (ORS),
and Clinical Treatment
{By selecting this option I agree that l will receive my CRS, IR/ORS and Clinical Treatment services from the "name of the PROS program" PROS program. I understand selection of this option means I will not receive CRS, IR/ORS or Clinical Treatment services from another PROS. I also will not receive services at a Continuing Day Treatment (CDT), Intensive Psychiatric Rehabilitation Treatment Program (IPRT), Prepaid Mental Health Plan (PMHP) or Clinic program.}
CRS and IR/ORS
{By selecting this option I agree that I will receive my CRS and IR/ORS services from the "name of the PROS program" PROS program. I understand selection of this option means I will not receive CRS and IR/ORS services from another PROS or receive services at an IPRT or CDT program.}
CRS and Clinical Treatment
{By selecting this option I agree that I will receive my CRS and Clinical Treatment services from the "name of the PROS program" PROS program. I understand selection of this option means I will not receive CRS or Clinical Treatment services from another PROS. I also will not receive services at a CDT, IPRT, PMHP or Clinic program. I will be able to receive IR/ORS services from another PROS program.}
CRS Only
{By selecting this option I agree that I will receive my CRS services from the "name of the PROS program" PROS program. I understand selection of this option means I will not receive CRS services from another PROS or receive services at a CDT or IPRT. I will be able to receive IR/ORS services from another PROS program.}
IR/ORS Only (vocational goals only)
{By selecting this option I agree to receive IR/ORS services from the "name of the PROS program" PROS program. I understand I am still able to attend a different PROS for CRS and Clinical Treatment (not IR/ORS services), or I can attend a CDT or a Clinic.}
| PROS Staff | PROS Registrant |
|---|---|
| Signature: | Signature: |
| Print Name: | Print Name: |
| Title: | Date: |
| Telephone Number: | |
| Date: | |
| Consent Agreement I understand that in order to register in the PROS program and in order to assure that Medicaid is appropriately billed for PROS services; the New York State Office of Mental Health may share my registration information with other mental health Medicaid providers. |
|
Please Maintain Copy in the Registrant's Case Record
Comments or questions about the information on this page can be directed to the Rehabilitation Services Unit.