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. |
|
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.