Document Type: The type of document required for completion of your application. Click on the hyperlinked text under this category for definitions of the type of document that needs to be uploaded.  

Upload File: Click the Browse button to upload the corresponding document from your computer.

Document Name: The document name field will populate with the file name (name of the document) as it appears on your computer. This field can be updated.

Required: If this document is required, a 'Y' indicator will be displayed in the grid. An 'N' will display if the document is not required, but can be uploaded if desired.

Uploaded User: Once a document is uploaded, this field will automatically display the name of the user who uploaded the document.

Uploaded Date: Once a document is uploaded, this field will automatically display the date of the upload.

Action: This grid field contains two buttons- the Edit button to add a document, and the Delete button to remove a document.

Note that if you want to add a document displayed in the grid, click on the Edit button in the Action column instead of the Add button above the grid.

Substance Use Disorder (SUD) PT 03 Behavioral Health Service Organization (BHSO) Tier Selections and PT 66 Behavioral Health Multi-Specialty Group:  

PT 03:  There are three tiers available for selection:  Tier 1 Mental Health, Tier 2 Outpatient SUD, and Tier 3 Residential SUD.  

PT 66:  No tier selections.    

• PT 03 Tier 1:  Will require upload of license, Certification of Accreditation (if selected Yes to currently accredited), and CLIA Certificate (as applicable).

• PT 03 Tier 2:  Will require upload of license, Certification of Accreditation (if selected Yes to currently accredited), OIG Letter and CLIA Certificate (as applicable).

• PT 03 Tier 3:  Will require upload of license, Certification of Accreditation (if selected Yes to currently accredited), OIG Letter and CLIA Certificate (as applicable).

• PT 66:  Will require upload of license and Letter for OIG in conjunction with license (if answered “Yes” to “Are you providing Substance Use Disorder Treatment (SUD)?” on Screen 1.1 Basic Information); CLIA Certificate (as applicable).  

Special Characters:

• The following Special Characters cannot be used in the situations below. Field properties will not allow the following characters in the box:

 For First Name, Business Name, Other name (if any):    | + \ '

 For Last Name field:    | + \ ', and numbers are not allowed

 For Comment Boxes:     <  >  ^  ~ ` + | \ / ¬ £

 For Address fields:    | + ! @ # $ ^ * ( ) ? / \ " < > & : ; _

• If you copy and paste an excluded special character, an error message will display after clicking Save & Next

• Remove excluded characters from pasted information or uploaded text in the document

Save & Next:

• When finished, click Save & Next to save the information and proceed to the next page

• Click Back to go to the previous screen without saving

• Click Exit to return to the dashboard without saving

• Note that if the information is not saved, you will lose the data on the current page