SUD Health Home Enrollment Documents
To be enrolled and participate in the Substance Use Disorder Health Home (SUDHH) program beneficiaries must meet eligibility requirements, including being enrolled in Medicaid or Healthy Michigan Plan, live within the 21 counties of NMRE region and have a qualifying diagnosis related to alcohol, stimulant or opioid use disorder.
To enroll an individual in SUDHH services through the NMRE, a Health Home Provider is required to submit the following information.
1) MDHHS 5515 - Consent to Share Behavioral Health Information for Care Coordination Purposes (Revision date of 3/20)
2) NMRE SUD Health Home Program Enrollment Consent - Clients sign the form to give consent to participate in the program. Admission to health home program is based on the date this form is signed.
3) Individualized Care Plan derived from an evidence-based assessment of need - The care plans should include all the conditions of the client and specify how the health home provider will coordinate and support clients in addressing their needs. (See care plan requirements in SUDHH handbook).
4) Treatment Needs Questionnaire screening tool - The tool should be given to clients to complete during their initial health home visit. It will be used to determine the treatment that is appropriate for the client and to assist the health home team in developing the care plan.
MDHHS 5515 Consent to Share Behavioral Health Information version 3.20.pdf
SUDHH Client Care Plan Template.pdf
Vermont Treatment Needs Questionnaire.pdf
NMRE SUD Health Home Enrollment Consent.pdf
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