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FORMS & APPLICATIONS

Licensing and Accreditation
COMAR 10.63 Application Process Steps for Accreditation-Based Licenses (amended 2.16.17)
COMAR 10.63 Licensure Application - Community-Based Behavioral Health Programs and Services
Guidelines for One-time Only Accreditation Assistance
Visit BHA's website for additional information.
MSBH / Core Service Agency
Consumer Support Requests (Special Needs / Pharmacy Assistance / Transportation Assistance)
Forensic Mental Health Referral
Optum's Maryland PBHS Provider Manual (Jan. 2020)
Release of Confidential Information
Residential Rehabilitation Program Application
RFP: FY23 Mental Health Case Management: Care Coordination For Children and Adolescents
Maryland Recovery Net (MDRN) SUD Client Support Services
Mid Shore Behavioral Health, Inc. provides financial assistance to consumers in the Public Behavioral Health System actively receiving substance use disorder (SUD) treatment. The consumer must reside in Caroline, Kent, or Queen Anne’s County (Dorchester and Talbot-contact local Health Department).
The purpose of the Maryland Recovery Net (MDRN) funds is to enable an individual to access or retain community-based SUD services; the funds should be linked to the client’s clinical and/or recovery support plan goals. The consumer must be engaged with the State Care Coordinator from their county of residence. The MDRN SUD Client Support Funds are limited to one-time annual help. The assistance may be used for pharmacy assistance, transportation to SUD related appointments, obtaining vital documents, medical assistance, and transitional support (including rental and utility assistance).
All applications are subject to evaluation and approval. Incomplete applications will be denied and returned.
Please fax or email applications to:
Fax 410-770-4809 | consumersupport@midshorebehavioralhealth.org
For questions, please contact:
Brigitte Kealy, Behavioral Health Coordinator Manager, 410-770-4801 ext. 320, bkealy@midshorebehavioralhealth.org
Maryland Recovery Net Client Support Services
Maryland Recovery Net Consumer Support Services
Pharmacy Assistance Request Form
Maryland Recovery Net
Consumer Transportation Request Form
Community
A.F. Whitsitt Center Referral
Channel Marker PRP and Support Employment Referral
Children's Choice Respite and PRP Program Referral
Case Management Referral - Crossroads Community
Main Street Housing Application
Maryland Coalition of Families Referral - Family Peer Support
Mobile Treatment - Mid Shore (Corsica River Mental Health)
Mobile Treatment - Lower Shore (Lower Shore Clinic)
Mobile Treatment - Cecil County (Upper Bay Counseling)
Targeted Case Management Plus Referral (revised 9.22.16)
TCM 1915(i) Care Coordination Referral (revised 9.22.16)
TCM Customized Goods and Services Request