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

To report a Sentinel Event please complete the Sentinel Event/Critical Incident Form and email the completed form to Sentinel.Events@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
• FY19 SUD-Budget Application Instructions
• FY19 SUD-Budget Forms Cost Reimbursement
• FY19 SUD-Budget Forms Fee-For-Service
• FY19 MH-Budget Forms Cost Reimbursement
• FY19 MH-Budget Application Instructions

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

Sentinel Event Policy and Reporting Forms

• Sentinel Event Protocol Rev 1
• Sentinel Event/Critical Incident Form
• Sentinel Event Root Cause Analysis-PIP

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

Expanded School Mental Health Forms

• ESMH- Provider Agency and School Assignment Directory SY 2013-2014
• HS-Provider-Assignment-Directory-SY-2013-2014
• ESMH and SUD Manual for ESMH
• ESMH Secure Log-In Form

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.