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Ann Marie T. Sullivan, M.D., Acting Commissioner
Governor Andrew M. Cuomo

Cancellation Form from Personalized Recovery Oriented Services (PROS)

For Use by Assertive Community Treatment (ACT) Programs

Date ____/____/_____

Recipient Information Provider Information
Name: Full Name:
Date of Birth: Address:
Gender: M or F Provider ID:
Social Security Number:: Locator Code:
Medicaid #:  

Cancellation of PROS Registration - Select One Option

To Attend ACT

{By selecting this option I agree to no longer receive services from "name of the PROS program" I understand I will able to re-register with this program at any time.}

ACT Staff PROS Registrant
Signature: Signature:
Print Name: Print Name:
Title: Date:
Telephone Number:  
Date:
Consent Agreement
I understand that in order to cancel my registration in the PROS program and in order to assure that Medicaid is appropriately billed; the New York State Office of Mental Health may share my registration information with other mental Health Medicaid providers.

Providers fax completed copy of this form to New York State OMH at (518) 473-8255 Attn: Joyce Billetts

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.