Provider Documents & Forms
Guidelines, Forms, and Links
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- Child-Adolescent Discharge/Transition Plan
- Criterion 5
- Health Safety Checklist
- Out of State Travel Form
- PCP/Provider Request for Care Manager Name or Assignment Referral Form
- Residential Openings
- Short Range Goals Templates (Dotx)
- Typical Weekly Schedule
- Typical Weekly Schedule Sample
- Universal Application for Youth Residential Placement Needs
- Learning Campus User Agreement
Please note: We also have a new process to request new users for Provider.MyLearningCampus.org. - Request access SFTP Claims Care Management
- ZixMail Instructions
These forms should be sent to ProviderEnrollment@TrilliumNC.org
- Child First® Request for Service Form
- Child with Complex Needs Referral Form
- Consent for Release of Member Information
- Consent for Release of Member Information (Español)
- Critical Incident / DHHS Incident and Death Report
- Cultural Competency Plan FY-2022-24
- HIPAA Work Area Privacy Safeguards
- Innovations Waiver - Relative/Guardian as Direct Service Employee
- Independent Practitioner Referral Form
- LOC Eligibility Determination NC Innovations Form
- Medicaid Clinical Coverage Policies 8A-8P
- NCDHHS NC SNAP - Assessment website
- Trillium Physical Health Prior Authorization
- NC-TOPPS: Services Requiring It
- NC-TOPPS: Important Users Link
- NC-TOPPS Implementation Guidelines
- Non-Covered State Medicaid Plan Services Request Form for Recipients under 21 Years Old
- Notification of Out-of-Home Placement Form
- Person-Centered Forms & Publications
- Plan of Correction
- Pharmacy Prior Authorization Forms
- Record Retention Form
- Records Management & Documentation Management
- Regional Referral Form for Admission to a State Psychiatric Hospital or ADATC
- Treatment Authorization Request (TAR) Form
- Worksheet for Requesting Exceptions to the Diversion Law (SB 859)
- Provider Change Form
If you are requesting site and service additions please email the specific request to NetworkServicesSupport@TrilliumNC.org - Hospital Registration Worksheet (Excel)
- The TFC/IAFT Additional Site Form has been removed. TFC/IAFT homes will no longer be added to the contracts. See Provider Communication Bulletin 008 for more information.
- AFL/Respite Additional Site Form
- Standardized Referral Form Updated (PDF)
- Standardized Referral Form Updated (DOCX)
Links and Resources
- Family Disaster Plan
- HIPAA
- NC Division of Health Benefits
- NC Division of Mental Health, Developmental Disabilities & Substance Abuse Services
- NC Tracks
- Trillium FAQ for NC Tracks
The “NCTracks Q and A” listserv is designed for LME/MCO use only, not for provider agencies. Provider agencies should call 1-800-688-6696 for technical assistance.
- Trillium FAQ for NC Tracks
- NC-TOPPS
- NC-TOPPS
- Involuntary Commitment Process
- PCP/Provider Request for Care Manager Name or Assignment Referral Form
- Psychiatric Recruitment Opportunities for Providers (Loan Repayment Incentives and Practice Opportunities)
- School of Government LME Programs
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