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Provider Forms and Documents

Competitive Procurement l Evidence Based Practice with Delinquent Youth l Forms
Resource Parent T4T l Provider Policies and Manuals
Provider Policy 30-day Review l Provider Scorecard l PBC Basic Principles l TennCare Help
Training l Contracting with DCS l Provider Training l TFACTS Web Based Training
TFACTS Documents

0705 Absconder/Runaway/Escapee/Recovery Checklist Instructions
0705 Absconder/Runaway/Escapee/Recovery Checklist

0950 AdoptUSKids Information Acknowledgement
0403 Appeal for Fair Hearing
0778 Application for Re-establishment of Foster Care Services * Spanish Version
0946 Assessment, Checklist and Protocol for Behavior and Risk for Victimization
0559 Authorization of Release of Information from DCS * Spanish Version
0206 Authorization for Routine Health Services for Minors
0927 Border Agreement Kinship Home Placement Checklist and Consent for Medical Treatment * Spanish Version
0928 Border Agreement Non-Custodial Immediate Safety Plan * Spanish Version
0929 Border Agreement Non-Custodial Consent for Transportation * Spanish Version
0427 Child’s Medical Record * Spanish Version
0677 Adoption Record Face Sheet (Closed)
0684 Confidentiality Agreement
0910 Confirmation of Review of Runaway Prevention Plan
0973 Contractor List of Owners and Board Members
0687 Background Check History and IV-E Eligibility Checklist
0741 Database Search Results
0553 Discipline Policy
0830 Dispute Resolution Request * Spanish Version
0940 Employee/Volunteer/Contractor Acknowledgement and Notification of Prison Rape Elimination Act (PREA)
0708 EPSDT Physical Examination
0691 Fingerprint Card Information * Spanish Version
0689 Health Services Confirmation and Follow up Notification
0780 Help Desk Ticket Request for Providers
0676 Home Safety Checklist
0496 Incident Report
0972 Individual Conflict of Interest Statement
0225 Individual Program Plan (IPP) Quarterly Review
0970 Individual Sub-Contract
0761 Independent Living Program Review Request * Spanish Version
0669 Information Services Customer Request
0627 Informed Consent for Psychotropic Medication
0460 Intent to Adopt Placement Agreement
0422 Mail and Acknowledgment of Case Records, Record Materials and Forms
0593 Medication Observation Record
0707 Medical Self-Report (Annual) Resource Parent/Child * Spanish Version
0431 Monthly Family Income and Expenditures
0450 Notice of Removal of a Child from a Resource Home
0158 Notification of Equal Access to Programs and Services and Grievance Procedures
0749 Penalty Letter for Harboring * Spanish Version
0960 Performance Based Contracting Formal Committee Review
0959 Performance Based Contracting Formal Review Request
0969 Performance Based Contractor (PBC) Sub-Contractor
Profile of Parenting Study Tool
0629 Psychotropic Medication Evaluation
0334 Request for Access to Human Subjects or Records, which may involve Informed Consent
0541 Request for Information
0435 Request for Name and/or Address of Father with Claim of Paternity * Spanish Version
0628 Request for Prior Approval of PRN Psychotropic Medication
0985 Request for Resource Home Transfer
0542 Research Involving Study of Existing Records or Data
0962 Resource Family History Questionnaire
0961 Resource Family Home Study
0963 Resource Family Reference Letter and Questionnaire
0895 Resource Family Strengths Needs Checklist * Spanish Version
0675 Resource Home Cover Sheet
0871 Resource Home Disaster Plan * Spanish Version
0773 Resource Home Addendum
0932 Resource Home Disclosure Acknowledgement * Spanish Version
0692 Resource Home Mutual Re-Assessment or Re-Activation * Spanish Version
0544 Resource Home Placement Checklist
0630 Resource Home Prescription Medication Record
0690 Resource Home Study and Family Update Checklist
0678 Resource Parent Medical Report
0670 Resource Parent Oath to Abide
0583 Resource Parent Waiver of Right to Appeal
0672 Shared Resource Home Authorization
0934 Special or Extraordinary Rate Justification
0674 Special or Extraordinary Rate Request
0971 Sub-Contract Request with Non-Performance-Based (PBC) Entities
0995 Survey of Alleged PREA Incidents
BI-0083 TN Bureau of Investigation (TBI) Missing Child Report
TennCare Medical Appeal
0944 TFACTS Access Request for Providers
0636 Title VI/Title IX Complaint
0594 Visitation Observation Checklist
0921 Waiver of Criminal, PATH Training Modifications, Non-Safety Issues, and CPS Substantiations
0543 Well-Being Information and History
0939 Youth Acknowledgement and Notification of Prison Rape Elimination Act (PREA)

Education
ADM Funding Calendar 2012 - 2013
Adult Education Enrollment Form
Average Daily Membership Form 2012 - 2013
District Calendar 2012 - 2013
Educational Placement Evaluation
Education Specialists Contact Information
High School Diploma Requirements
Roster of Graduates
Sample Report Card for Non-Public Schools
Sample Student Transcript for Non-Public Schools
Special Education Invoice Form