Treatment Forms
Critical Incident Reporting Form Word | PDF
Licensed or contracted agencies are required to report critical incidents
(serious and significant adverse incidents) to the Office of Substance
Abuse. Instructions for completing and submitting critical incident
information are on this form. Examples of incidents that are provided
on the form are not all-inclusive. Since programs must exercise judgment
in reporting incidents, reporting staff are encouraged to contact OSA regarding
any questions about whether an event is reportable. If you
have any questions, please contact Deborah.Doiron@maine.gov or call 287-2595.
The Office of Substance Abuse has developed a Waiting List Form as part of
Maine's Block Grant requirements that the waiting list information be collected.
A copy of the form and the instructions on properly completing and submitting
the report are linked. Paper copies are also available. For a copy, email Mary.Beaudoin@maine.gov.
Agencies are also invited to create their own form electronically if easier.
However, the fields must be the same as on the OSA form and they must be in
the same order.
Waiting List Form Instructions Word | PDF
2005 Maine Outpatient Service Delivery Form Excel | PDF
Outpatient Service Delivery Forms are used by agencies contracted by the Office
of Substance Abuse to report ambulatory units of service. The forms are completed
monthly and sent to the Office of Substance Abuse by the 15th of the month
following the month the services were delivered in. Example: April units of
service are sent to the Office of Substance Abuse by May 15th.
This form was revised in July 2001. Note that the most important revisions
are 1) DSAT reporting and 2) intensive outpatient units should be reported
as daily units to correspond with a change in Medicaid reporting. If you have
any questions on how to properly complete this form, please contact the Helpdesk
at 287-4699 or by email at TDS.Helpdesk@maine.gov.
Please print and copy as needed.
Many of the documents listed on this page are in PDF format. The free Adobe Acrobat Reader is
necessary to view them. Printouts of these documents are also available
upon request.
