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  • DWIHN Member Orientation Receipt Form

  • I hereby acknowledge that I was presented with an Orientation Packet and provided information on the services, benefits and how to access them. I was also provided the opportunity to ask questions and given the phone number to call should I have any additional questions at a later time.

  • I Received the Following Information:

     

    • DWIHN Member Handbook
    • DWIHN Customer Service Provider Directory
    • MDHHS Recipient Rights Handbook
    • DWIHN Customer Service Brouchures
      • How Customer Service Can Help You
      • Understanding Grieveances and Appeals Bookmark
      • How to Access Routine Behavioral Health Services
      • How to Obtain Emergency and After Hours Behavioral Health Services
      • Advance Directives for Medical & Behavioral Health Care
      • Kevin's Law
      • Member's Rights and Responsibilities
    • Service Provider Informational Materials
    • Estimated Cost of Service Form
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Star Center, Inc.
    13575 Lesure
    Detroit, MI 48227
    Phone: 313-493-4410
    Fax: 313-493-4415

  • Medicaid Recipient of Substance Abuse ServicesComplaint/Grievance Right Process

  • A Medicaid Recipient of Substance Abuse services may file a complaint or grievance on any aspect of service provided to them by the contracted providers or Coordinating Agency. A complaint may be oral or in writing and submitted by the patient or their representative to the provider.
  • If the recipient is not satisfied with the outcome of the decision at the provider level, the recipient may file a complaint/ grievance with their Coordinating Agency on a form provided by the provider or through the Coordinating Agency.
  • A Medicaid recipient will have the opportunity to present their grievance within fifteen (15) business days of receipt of the grievance. A review will be expedited if the time frame would seriously jeopardize the life of a patient.
  • The Coordinating Agency will provide the client with the necessary information on the right to appeal to the Michigan Department of Community Health to receive a fair hearing as well as the form needed if they are not satisfied with the outcome of the grievance. The patient has the right to represent himself or use legal counsel, relative, friend or other spokesperson.
  • Please note: THIS PROCESS IS DIFFERENT THAN FILING A RECIPIENT RIGHTS COMPLAINT. RECIPIENT MAY ALSO FILE A RECIPIENT RIGHTS COMPLAINT UNDER THE ADMINISTRATIVE RULES FOR SUBSTANCE ABUSE SERVICE PROGRAMS.

  • STAR CENTER, INC.

    13575 LESURE

    DETROIT, MI

    PHONE: 313 493-4410

    FAX: 313 493-4415

  • This Adequate Notice of Action for Medicaid Beneficiaries is being given to you following your recent Individualized Plan of Service (IPOS) development, amendment or periodic review. Your IPOS amendment/periodic review defines the amount, scope, duration and commencement date for services and supports. Services will start within 14 (calendar) days from the agreed upon start date.

  • ACTION EFFECTIVE ON:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Legal Basis for the above decision is 42CFRSS.)230(d)

  • If you do not agree with your plan or the action taken by your Service provider, you can ask for an Appeal. A Local Appeal is a review of the Action by someone who was not part of the decision-making that lead to the action you are appealing; and who has the skills to review the action. The two types of Appeals are described below. You can request a Local Appeal and a Medicaid Fair Hearing at the same time or separately.

  • Medicaid Fair Hearings

    • You have up to (90) (calendar) days from the date of the Notice of Action to ask for a Medicaid Fair Hearing.
    • To request a Medicaid Fair Hearing, fill out the "Request for Hearing" form that came with this Notice of Action and mail it in the pre-paid envelope provided. You can also mail it yourself:
  • STATE OFFICE OF ADMINISTRATIVE HEARINGS AND RULES
    FOR DEPARTMENT OF COMMUNITY HEALTH
    ADMINISTRATIVE TRIBUNAL
    P.O. BOX 30763
    LANSING, MI 48909
  • If you have any questions you can contact the Administrative Tribunal directly at: 1-877-833-0870
  • You can choose to have another person represent you at the State Administrative Hearing. If you do want someone else to represent you then you have to give that person permission in writing. On the "Request for Hearing" form you will have to fill out Sections 2 and 3.
  • The person you choose to represent you can be anyone you choose as long as:
    1. He/she is 18 years old.
    2. You have given them written permission of the "Request for Hearing" form by checking YES in Section 2 and having the person representing you fill out Section 3. You will need to fill out Section 1
    3. Your guardian or conservator can represent you if a copy of the Court Order naming the guardian/conservator is sent with the "Request for Hearing" to the Administrative Tribunal.
  • If you ask for a State Administrative Hearing within 12 (calendar) days from the date of the Notice of Action; or if your services were reduced, terminated or suspended without advance Notice of Action, the Service Provider has to reinstate services until an Administrative Law Judge makes a decision. If you have continued to receive services while the decision was being made, and the Administrative Law Judge decides the Service Provider decision was correct, you might be responsible for the cost of the services provided during that time.
  • You can contact your Service Provider to help you with reviewing your case file before and while the State Administrative Hearing is pending to look for things that will support your case. You will be able to present information in person and/or writing prior to and during the State Administrative Hearing before a decision is made.
  • You can request a faster hearing if waiting would put your ability to reach, keep or get back to your maximum functioning level seriously at risk. To ask for a faster State Administrative Hearing you must call 1-877-8330870.

  • Local Appeal

    • You have up to 45 (calendar) days from the date of the Notice to ask for a Local Appeal.
    • You can ask for a Local Appeal in two ways:
      1. Fill out the "Request for Local Appeal" form that came with this Notice of Action and give it to your Service Provider who will send you a letter saying they received your "Request for Local Appeal".
      2. You can call your Service Provider to tell them that you want to file a Local Appeal. They will fill out the "Request for Local Appeal" forın for you and arrange for review of action by a person with clinical Expertise that was not part of the decision making that led to the action you are appealing. If you have any Questions or need help filing a Local Appeal, you can contact your Service Provider and/or D-WCCМНА Customer services at 313-833-3232/TDD 800-630-1044.
    • You can contact your Service Provider to help you with reviewing your case file before and during the Local Appeal to look for things that will support your case. You will be able to present information in person and/or writing to the Appeals Coordinator before a decision is made.
    • You can choose to have someone help you with your Local Appeal. You can also choose someone to represent you during the Local Appeal.
    • If you ask for a Local Appeal with in 12 (calendar) days from the date of Notice or if your services were reduced, terminated or suspended without Advance Notice of Action, the Service Provider has to reinstate services until the Appeals Coordinator makes a decision.
    • You can ask for expedited (faster) Local Appeal if waiting would put your ability to reach, keep, or get back to your maximum functioning level seriously at risk. To ask for a faster Local Appeal tell your Service Provider that you need one.

  • Contact your service provider with questions and to file Local Appeals
    Star Center, Inc., 13575 Lesure, Detroit, MI 48227
    Phone #313 493-4410 Fax# 313 493-4415

  • MY SIGNATURE INDICATES THAT I HAVE BEEN GIVEN INFORMATION ON MY RIGHT TO A LOCAL APPEAL AND MEDICAID FAIR HEARING.
  • Notice Date:
     / /
    2 digit month, 2 digit day, 4 digit year
  • Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Birth Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • *
    Rows
  • Star Center, Inc.
    13575 Lesure
    Detroit, MI 48227
    Phone (313) 493-4410
    Fax (313) 493-4415

  • Michigan Department of Community Health
    Administratve Tribunal
    NOTICE OF HEARING Rights
    Substance Abuse Treatment Service Authorization

  • Date:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • You have been authorized to receive substance abuse treatment services. Detroit Wayne Integrated Health Network [(DWIHN, the coordinating agency (CA)) is responsible for the authorization of these services. The legal basis for any utilization review decisions is 42 CFR 440.230(d).
  • If you do not agree with this scope, duration, or intensity of the services included in this authorization for substance abuse treatment services, you may request a Michigan Department of Community Health administrative hearing before an administrative law judge. The request must be in writing, signed by you and your authorized hearing representative, and received by the DWIHN within 90 days of the date of your authorization.
  • To request an administrative hearing, complete the "Hearing Request" form, and mail to:
  • Administrative Tribunal
    Michigan Department of Community Health
    PO Box 30195
    Lansing, MI 48909-7695
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  • Methadone Maintenance Client Agreement

  • It is the policy of Detroit Wayne Mental Health Authority (DWHMA) that all patients requesting methadone treatment follow DWHMA process for evaluation prior to being authorized to receive services by a Methadone provider.
  • 1. I agree to comply with the rules and guidelines set forth by the Methadone Provider. If I do not, I may be put on probation and/or administratively detoxed from the methadone clinic.
  • 2. I agree to become free of illicit substance within 90 days of enrollment.
  • 3. I agree that persistent and poor outcomes will result in probation status for non-compliance after 90 days.
  • 4. I understand that I will be evaluated every 4 months to monitor my toxicology screens and to view my progress towards my treatment goals.
  • 5. I agree to abide by my treatment plan and expect to show progress towards meeting treatment plan goals and objectives. Failure to show progress towards treatment plan goals and objectives may result in another treatment modality such as: detox, buprenorphine, short or long term residential.
  • 6. I agree to work towards goals and objectives that will rehabilitate me to either become drug free or assume financial responsibility for continued treatment.
  • 7. I understand that I am to authorize communications between my prescribing clinic/doctor and my methadone clinic in order to coordinate the best care for me.
  • 8. I understand that I may be funded by DWHMA for a time period of up to two years or less, depending upon my progress.
  • I have read and understand my expectations and it was explained to me. I agree to comply with the Methadone Client Agreement.
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