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Forms
	Account Request Form		Member/Claims Transfer, Instructions for
	Claims Correction Form, MACSIS HIPAA (Draft)		Completing
	[Word] [PDF]		•Member/Claims Transfer Request Form
	•Instructions for Completing MACSIS HIPAA		[Word] [PDF]
	Claims Correction Form		Member Enrollment Form
	Disclosure of Information Form (Board Staff)		•Member Enrollment Form - Instructions for
	HIPAA Service Rate Form (Tier 2)		Completion
	• ODADAS Service Codes		Provider Request Modification Form
	[Excel] [PDF]		[Word] [PDF]
	• ODMH Service Codes		Report Request Form
	[Excel] [PDF]		Request to Remove Client from MACSIS
	•HIPAA Service Rate Form (Tier 2) Instructions		Residency Dispute Determination
	MACSIS EDI Claims Testing Req. Form		Form-ADM038
	[Word] [PDF]		Residency Verification Form
			TCP/IP Access Request Form (Unix Accounts)