To file a complaint about a provider fill out the Complaint Form and send it to complaints@bhsbaltimore.org.

To report a critical incident please complete the Critical Incident Form and email the completed form to critical.incident@bhsbaltimore.org.

For more information about the complaint process contact Diana Long, Incident Management & Investigations Manager at Diana.Long@bhsbaltimore.org.

Because each funding opportunity may call for different forms, be sure to check the Word document attached to ensure that the required forms are submitted. Please see individual description for the correct person to contact with questions or concerns.

Budget Forms

• FY20 MH-SUD Budget Forms Cost Reimbursement
• FY20-Budget-Forms-Fee For Service

Contract Attachments

• BHSB FY20 Contract Status Memo
• Attachment D – Debarment and Suspension Certification

Other Forms

• W-9
• Insurance Requirements
• Human Service Agreements Manual
• Request for Client Support
• Agreement to Cooperate

Critical Incident Form

• Critical Incident Form

Forms for Supporting Youth/Caregivers

• Youth Support Request Form
• Request Respite Form

Request Form for Letters of Support

• Request Form for Letters of Support

Financial Reports Due Dates

• FY20 Cost Reimbursement Contracts Fiscal Reporting Schedule

Capitation Provider Forms (Reporting and Budget)

• Monthly Capitation Project Report Form
• Program Budget Form
• Semi-Annual Fiscal Report
• Capitation Project Management Plan Template
• Capitation Application

Outcome Reporting Forms

• State Mobile-ACT (Please call 443-615-7806 for instructions and the password for this form.)
• Psychiatric Rehabilitation Program
• Residential Rehabilitation Program
• Supportive Employment Program

If you have any questions related to the data reporting forms, please call 443-615-7806.