Benefits - America Back To Top
401k Retirement Plan - Annual Report Summary - 2019 Shannon Tulloch 01/18/19
403b Retirement Plan - Annual Report Summary - 2019 Shannon Tulloch 01/18/19
ASPCA Pet Health Insurance Shannon Tulloch 11/30/18
Centerstone Florida 2019 Benefit Guide Shannon Tulloch 10/12/18
Centerstone Illinois 2019 Benefit Guide Shannon Tulloch 10/12/18
Centerstone Indiana 2019 Benefit Guide Shannon Tulloch 10/12/18
Centerstone Kentucky 2019 Benefit Guide Shannon Tulloch 10/12/18
Centerstone Tennessee 2019 Benefit Guide Shannon Tulloch 10/12/18
Centerstone Wellness Program (IL, IN, TN) 11/30/18
Instructions for locating BCBST Physician Biometric form (IN, TN) Shannon Tulloch 11/30/18
Wellness Reimbursement Request (IL, IN, TN) 11/30/18
Business Associate Agreements - America Back To Top
America Business Associate Agreement Sherry Harrison 08/08/17
Cover Letter for Business Associate Agreement Sherry Harrison 07/16/14
Cell Phone Communications - America Back To Top
Cell Phone Overage Payment Form Help Desk 08/27/14
Cell Phone Payroll Deduction Form Help Desk 05/15/13
IT Equipment Damaged, Lost, or Stolen Form Help Desk 08/27/14
Pager Request Form Help Desk 05/15/13
Verizon Wireless Employee Discount Enrollment Help Desk 05/15/13
Central Region - Clinical - Indiana Back To Top
ACT Referral Form 08/03/10
CANS Optional Family Friendly Interview 07/16/14
Crisis Only Status 11/17/09
Institutional Level of Care/Auchenbach Form - Children 07/16/14
Red Oak Center Referral 07/16/14
School-Work Appointment Verification Form – Scottsburg 01/31/17
Summer Youth Program Referral Form 11/17/09
Central Region - Miscellaneous - Indiana Back To Top
Authentication of Business Records 11/17/09
Medicaid Waiver 11/17/09
Medication Call-In 11/17/09
Clinical - All Indiana Regions - Indiana Back To Top
Centerstone Psychiatric Services – client informational sheet 11/23/16
DMHA SOF Adult Referral Form 07/16/14
Employee Exposure Follow-up Record 05/20/10
Exposure Incident Report - Indiana 05/04/18
Glucometer Blood Sugar Screening Competency Post-test 05/07/10
Hepatitis B Vaccination Consent/Waiver for Employees 05/20/10
Infection Control Report 05/21/10
NAPPI - Lalemand Behavioral Scale (Green Scale) Jessica Rabiola 07/16/14
NAPPI - Lalemand Behavioral Scale (Red Scale) Jessica Rabiola 07/16/14
Peer Review Process Checklist 05/07/10
SOF Adult Referral Update - Attachment A 07/16/14
SOF SED Referral Justification - Attachment B 07/16/14
Urine Drug Screening In-office Testing Competency Post-test 05/07/10
Clinical Forms - Illinois Back To Top
Complaint and Grievance Form for Clients Jennifer Johnson 11/07/17
Corrective Action Plan 07/11/14
Corporate Communications - America Back To Top
Adult Client Media Consent Form Mindy Tobin 06/30/11
Child/Youth Client Media Consent Form Mindy Tobin 01/13/16
Client artwork - permission release form Nicholas Spagnolo 11/05/18
Display Printed Materials and Promo Items Reservation/Request David Schrader 02/08/17
Organizational Identity Graphic Standards 10/17/12
Potential Media Issue Mindy Tobin 07/16/14
User Guide for The Source Zain Syed 05/24/18
East Region - Clinical - Indiana Back To Top
OP Admitting - 831 Dillon, Med Srvcs 03/10/10
OP Admitting - Connersville 08/26/10
OP Admitting - Richmond, CSS 03/10/10
OP Admitting - Winchester 12/09/13
Payeeship Monthly Budget and Budget Change Form 05/14/10
School-Work Appointment Verification Form - 200 North 13th Street Susan Points 10/11/16
School-Work Appointment Verification Form - 325 South Oak Street 10/11/16
School-Work Appointment Verification Form - 54 South 15th St. 10/11/16
School-Work Appointment Verification Form - 831 Dillon Drive 10/11/16
School-Work Appointment Verification Form - Connersville 10/11/16
School-Work Appointment Verification Form - New Castle Tiffany Byers 10/11/16
School-Work Appointment Verification Form - Rushville 10/11/16
School-Work Appointment Verification Form - Union City 10/11/16
East Region - Staff - Indiana Back To Top
Meeting Minutes Format 07/16/14
Fax Cover Sheets - IL - Illinois Back To Top
Alton - 2615 Edwards Street Alexandra Cope 10/06/15
Jerseyville - 221 East County Road Alexandra Cope 10/06/15
Fax Cover Sheets - IN - Indiana Back To Top
Bedford, 1315 Hillcrest Road 10/06/10
Bedford, 2621 Industrial Park Drive, Bedford Apartments 10/06/10
Bloomington, 100 Westplex Drive, Westplex Apartments 10/06/10
Bloomington, 120 North Hopewell Street, Cardinal House 10/06/10
Bloomington, 121 North Hopewell Street, Hopewell Apartments 10/06/10
Bloomington, 221 North Rogers Street, Recovery House 10/06/10
Bloomington, 322 South Grant Street, Grant Street House 10/06/10
Bloomington, 416 West First Street, First Street House 10/06/10
Bloomington, 645 South Rogers Street 10/06/10
Bloomington, 645 South Rogers Street, Human Resources 10/06/10
Bloomington, 653 South Rogers Street, Hoosier House 10/06/10
Bloomington, 714 South Fairview, Fairview Apartments 10/06/10
Bloomington, 714 West Wylie Street, Wylie House 10/06/10
Bloomington, 809 West 1st Street, Transitional Care Facility 10/06/10
Bloomington, 817 West 1st Street, Foster Care Select 10/06/10
Bloomington, 823 North Maple Street, Blair House 10/06/10
Camby, 13896 North Ferguson Road, Sugarwood Apartments 10/06/10
Columbus, 1714 Cottage Avenue, Caldwell House 10/07/10
Columbus, 2412 Indiana Avenue, Weinland House 10/06/10
Columbus, 2650 Foxpointe Drive, Indiana House 10/06/10
Columbus, 2999 Ninth Street, Mapleview Apartments 10/06/10
Columbus, 720 North Marr Road 10/06/10
Columbus, 720 North Marr Road, Access Services 07/25/13
Columbus, 720 North Marr Road, Front Hall Fax 10/06/10
Columbus, 720 North Marr Road, Medical Records 10/06/10
Columbus, 720 North Marr Road, Suite 100 10/06/10
Columbus, 720 North Marr Road, Suite 200 10/06/10
Columbus, 720 North Marr Road, Suite 300 10/06/10
Columbus, 720 North Marr Road, Suite 300 (2) 10/06/10
Columbus, 730 Schnier Street 10/06/10
Connersville, 390 East Erie Street 10/06/10
Connersville, 392 East Erie Street, Alberta Hopper House 10/06/10
Greencastle, 1542 S. Bloomington St. Suite 1300, Johnson Nichols Health Clinic 10/30/14
Greensburg, 1530 Commerce Park West Drive 10/06/10
Greensburg, 325 Smith Road, Cedarview Apartments 10/06/10
Madison, 3008 North Bevcher Drive 10/06/10
Madison, 3100 North Bevcher Drive, Willowview Apartments 10/06/10
Martinsville, 1025 Morton Avenue, Plaza Apartments 10/06/10
Martinsville, 1175 Southview Drive 10/06/10
Mooresville, 11370 North SR 67 10/06/10
Muncie, 2809 West Godman Avenue 03/30/16
Nashville, 91 West Mound Street 10/06/10
New Castle, 3337 S. State Road 3, Foster Care Select 04/21/15
New Castle, 3337 S. State Road 3 South Memorial Drive 04/21/15
North Vernon, 1260 East Buckeye Street 10/06/10
North Vernon, 299 West Hayden Pike, Aspen House 10/06/10
North Vernon, 601 North Henry Street, Pineview Apartments 10/06/10
Richmond, 115 North Thirteenth Street, Serenity House Susan Points 11/09/11
Richmond, 151 South 52nd Street #19, Cumberland Apartments 10/07/10
Richmond, 1811 South Ninth Street, English Manor 10/06/10
Richmond, 200 North Thirteenth Street, Samuel Gaar Resource Center 10/06/10
Richmond, 301 Kinsey Street, Kinsey Transitional Living 10/06/10
Richmond, 54 South Fifteenth Street, Community Support Services 10/06/10
Richmond, 54 South Fifteenth Street, ETS 10/06/10
Richmond, 76 South Fourteenth Street, Peer Horizons 10/06/10
Richmond, 76 South Fourteenth Street, Pierson House 10/06/10
Richmond, 809 Dillon Drive 10/06/10
Richmond, 809 Dillon Drive, Accounting 10/06/10
Richmond, 809 Dillon Drive, Benefits 10/06/10
Richmond, 831 Dillon Drive, Administration 10/06/10
Richmond, 831 Dillon Drive, Medical & Nursing 10/06/10
Richmond, 831 Dillon Drive, Medical Records 10/06/10
Rushville, 1400 North Cherry Street 10/11/16
Seymour, 1216 Hillcrest Drive 10/06/10
Seymour, 1443 Corporate Way 10/06/10
Seymour, 711 Marley Lane, Oakview Apartments 10/06/10
Spencer, 272 North US Highway 231 10/06/10
Spencer, 645 W. Morgan, Johnson Nichols Health Clinic 10/30/14
Union City, 224 North Columbia Street 10/06/10
Winchester, 325 South Oak Street, Suite 103 10/06/10
Fax Cover Sheets - TN - Tennessee Back To Top
6110 Shallowford Rd., Chattanooga, TN - 57001 03/07/17
Adult Case Management - 19001 Melinda Collins 03/07/17
Ashland City, 162 County Services Drive - 11002 Melinda Collins 03/07/17
Career Resource Center Columbia 07/07/10
Career Resource Center Tullahoma 07/07/10
Centerstone Research Institute Melinda Collins 11/18/09
Clarksville, 118 Union Street, Oak Hill Residential - 63012 Melinda Collins 03/07/17
Clarksville, 125 Vivian Street, Vivian House - 63014 Melinda Collins 03/07/17
Clarksville, 1820 Memorial Circle, Centerstone Associates - 63011 Melinda Collins 03/07/17
Clarksville, 404 Pageant Lane, Cumberland Valley Group Home - 63005 Melinda Collins 03/07/17
Clarksville, 404 Pageant Lane, Regional Intervention Program (RIP) - 63005 Melinda Collins 03/07/17
Clarksville, 511 8th Street, Harriett Cohn Center - 63001 Melinda Collins 03/07/17
Clarksville, 812 Greenwood Avenue, Weems Academy - 63004 Melinda Collins 03/07/17
Clarksville, 901 Martin Street, The Lodge - 63007 Melinda Collins 03/07/17
Cleveland, 4160 North Ocoee Street - 06005 10/23/18
Columbia, 1222 Medical Center Drive - 60001 Melinda Collins 03/07/17
Columbia, 230 E. James Campbell, Ste. 113 03/07/17
Columbia, Post Office Box 1197 - 60004 Melinda Collins 03/07/17
Cookeville, 13 South Jefferson Avenue - 71001 Lindsay Vinson 09/15/17
Cookeville, 606 East Spring Street - 71002 Rhonda DeVore 07/31/18
Corporate office 03/07/17
Crisis Management Strategies Melinda Collins 11/18/09
Dickson, 721 Highway 46 - 22001 Melinda Collins 03/07/17
Dickson, 805 North Charlotte Street - 22004 Melinda Collins 03/07/17
Estill Springs, 416 South Main Street - 26000 Melinda Collins 03/07/17
Fayetteville, 2241 Thornton Taylor Parkway - 52001 Melinda Collins 03/07/17
Gallatin, 332 Sumner Hall Drive - 77001 Melinda Collins 03/07/17
Health Information Management - 19028 Melinda Collins 03/07/17
Hohenwald, 912 Summertown Highway - 51001 03/07/17
Lawrenceburg, Post Office Box 865 - 50001 Melinda Collins 03/07/17
Lewisburg, 1601 Nashville Highway - 59003 Lisa Crane 03/07/17
LIFESolutions - ReConnect, Columbia - 60009 Melinda Collins 03/07/17
LIFESolutions ReConnect, Dickson - 22002 Melinda Collins 03/07/17
LIFESolutions ReConnect, Shelbyville - 02003 Melinda Collins 03/07/17
Madison, 620 South Gallatin Road - 19001 Melinda Collins 03/07/17
Nashville, 1921 Ransom Place, Frank Luton Center - 19007 Melinda Collins 03/07/17
Nashville, 230 Venture Circle - 19005 Melinda Collins 03/07/17
Nashville, 2400 White Ave. Dede Wallace - 19003 Jenn Waggoner 03/07/17
Nashville, 2410 White Ave., Technology - 19002 Melinda Collins 03/07/17
Nashville, 44 Vantage Way, Corporate Headquarters - 19023 03/07/17
PCP Communication Mandi Hodges 12/14/15
Pulaski, 1002 Brindley Drive - 28001 Melinda Collins 03/07/17
School-Based Services - 19032 Melinda Collins 03/07/17
Tullahoma, 1803 North Jackson Street - 16001 Melinda Collins 03/07/17
Tullahoma, 709 Davidson Street - 16002 Melinda Collins 03/07/17
Tullahoma, 709 N Davidson St, ReConnect Mindy Tobin 05/11/11
Tullahoma, Community Living Center - 16003 Melinda Collins 03/07/17
Waynesboro, Post Office Box 752 - 91001 Melinda Collins 03/07/17
West Nashville, 4525 Harding Pike Suites 235 & 236 - 19042 03/07/17
Finance - America - America Back To Top
2017 W4 for Federal Tax Exemptions Michelle Bacher 05/18/17
COA Tax Exemption Certificate Cyndi Edens 07/25/16
Payroll and Accounts Payable Direct Deposit Authorization Form Michelle Bacher 09/25/17
Requisition Form Cyndi Edens 06/18/18
Workday - Lost/Missing Receipt Form Cyndi Edens 01/04/19
Finance - IN - Indiana Back To Top
Activity Codes 07/01/10
Advance Check Authorization Form Cyndi Edens 03/08/13
Advance Check Receipts Cyndi Edens 05/05/17
BPSLive Online Purchasing System User Guide Kim Middleton 05/05/16
Cellular Phone Reimbursement Sherry Barker 07/16/14
Client Assistance Reference Chart 2017 Michelle Sears 06/07/17
Indiana General Ledger Expense Codes 07/01/11
Mileage Expense System Training Manual 01/15/15
Procedure Code to Activity Code Crosswalk Sheet 11/18/09
Purchase Requisition/Order Form Cyndi Edens 03/08/13
Request for New Activity Code/Fee Change Kay Brown 03/08/13
Requisition Form - Excel Tonia Hitchcox 07/22/14
Signature Authority Levels Cyndi Edens 01/11/16
Finance - TN - Tennessee Back To Top
Advance Check Authorization Form Cyndi Edens 03/08/13
Advance Check Receipts Cyndi Edens 06/01/17
Centerstone Client Assistance Application Camille Arendt 01/24/19
Centerstone GL Account Codes (Master List) Gary Eckardt 12/11/18
Client Assistance Federal Poverty Guidelines Camille Arendt 01/24/19
CRI Tax Exemption Certificate Cyndi Edens 07/25/16
CTN Tax Exemption Certificate Cyndi Edens 12/01/16
Mileage Expense System Training Manual 01/15/15
Payroll and Accounts Payable Direct Deposit Authorization Form Michelle Bacher 09/25/17
Purchase Requisition/Order Form Cyndi Edens 03/08/13
Purchase Requisition/Order Form Editable Cyndi Edens 10/09/17
Request for New Activity Code/Fee Change Kay Brown 03/08/13
Signature Authority Levels Cyndi Edens 07/13/17
Single Case Agreement Template Tara Highfill 06/18/15
Travel Form (Multiple Page Version) Cyndi Edens 07/16/14
Travel Form (Single Page Version) Cyndi Edens 07/10/14
Foundation - America Back To Top
CARES Guidelines - FY18 - CIN Lyn Morgan 10/05/18
CARES - Requisition Form - FY19 - CIN Lyn Morgan 11/14/18
(CTL) Staff Mini-Grant Guidelines and Application Jeney Slusser 08/26/16
Donation Form Nancy Low 03/25/15
Donation Form-Donor Not Present Nancy Low 12/07/17
Donation Pledge Form Nancy Low 03/26/15
Donation Process Nancy Low 03/25/15
FY19 CARES Campaign Donation Form Nancy Low 11/05/18
FY19 CARES Campaign FAQs Nancy Low 11/05/18
FY19 CARES Campaign Incentives Nancy Low 11/05/18
Gift In Kind Form Nancy Low 12/09/16
Volunteer Agreement Kathy Rogers 06/23/14
Health & Safety - Tennessee Back To Top
Emergency Box Checklist Brittany Haemmerlein 12/19/18
Employee Health Clinic Assignments Kathy Rogers 12/19/18
Employee Health Consent/Declination of Hepatitis B Vaccination Brittany Haemmerlein 12/12/12
Employee Health Consent for Influenza (Flu) Vaccination Brittany Haemmerlein 12/12/12
First Aid Kit Checklist Kathy Rogers 07/16/14
Flu Addendum for Pregnant Women Brittany Haemmerlein 09/30/14
Medical Referral List Mary Moran 10/28/13
PAP Medication Log Brittney Haemmerlein 06/29/15
Refrigerator and Oxygen Checklist Kathy Rogers 07/16/14
Sample Inventory Reconciliation Log Brittany Haemmerlein 06/29/15
Sample Sign-Out Sheet Brittany Haemmerlein 06/29/15
Tuberculosis Consent Form Brittany Haemmerlein 08/19/15
Human Resources - America - America Back To Top
2018 Holiday Calendar 12/13/17
AAA Employee Discount Information Lillie Wiggins 11/21/16
Application For Employment Ben Hall 05/05/16
Background Check Authorization Form Ben Hall 05/05/16
Catalytic Coaching Sheets Dan Smith 11/21/16
Centerstone Workers Comp Procedures - TN and IN Monica Dillard 03/14/17
Child Protection Services History Check Form and Instructions Ben Hall 05/05/16
Corrective Action Form Dan Smith 08/16/17
Costco Membership Discount Information Lillie Wiggins 01/04/17
Counseling Form Dan Smith 06/29/17
Credentialing Application Dan Smith 11/21/16
Dell Payroll Deduction Form Cindy Pegg 10/11/17
Disclosure Statement: Criminal Convictions Related to Medicare & Medicaid Programs Dan Smith 11/21/16
Emergency Medical Information Kathy Rogers 08/07/13
Employee Referral Form Dawn Kutruff 01/08/18
Employment Reference Check (Internal Transfer) Ben Hall 07/16/14
Employment Verification and Reference Check Ben Hall 05/05/16
FAQ for Non Exempt Employees Dan Smith 11/21/16
First Report of Work Injury - Indiana Monica Dillard 03/14/17
First Report of Work Injury - Tennessee Monica Dillard 03/14/17
FMLA Poster Dan Smith 11/21/16
GHG Correction Form Pam Warner 09/30/16
I-9 08/21/17
ID Badge and Key Request - Indiana Employees Christi Brown 09/30/16
Indiana State Tax WH4 Form Adelaide Wetzel 09/30/16
Instructions on Applying for an NPI Number Dan Smith 11/21/16
Involuntary Termination Form Dan Smith 11/21/16
Liberty Mutual Centerstone Flyer Lillie Wiggins 09/23/15
Liberty Mutual Quote Sheet Lillie Wiggins 09/23/15
New Hire Requirements-Tennessee Ben Hall 05/05/16
New Staff Member Checklist Ben Hall 05/05/16
Payroll Deduction for Licensure Fees Lillie Wiggins 06/23/17
Payroll Direct Deposit Authorization Michelle Bacher 09/25/17
Release Form 01/19/18
Request for Family/Medical Leave of Absence Monica Dillard 11/21/16
Request for Reasonable Accommodation Dan Smith 11/21/16
Sam's Club discount - Tennessee 03/29/17
Students Agreement Ben Hall 05/05/16
Supervisor Exit Interview Checklist - Indiana Shannon Tulloch 06/17/14
Tickets at Work Information Lillie Wiggins 09/18/15
TN - Performance Review/ Employee Evaluation Form Tonya Gilbert 02/01/19
Tuition Assistance Application Lillie Wiggins 02/21/17
Understanding Your Pay Michelle Bacher 07/02/18
W4 - 2018 Federal Form 06/13/18
YMCA 2016 Corporate Rates for Centerstone Lillie Wiggins 10/06/17
YMCA Application Lillie Wiggins 10/06/17
Human Resources - IL - Illinois Back To Top
Allstate Critical Illness Brochure (for IL) Bonnie Sprague 05/14/15
Contribution Change Form Bonnie Sprague 05/14/15
Employee Referral Form - CIL Scott Kopperlund 05/02/18
IL Employee Benefits Summary Bonnie Sprague 05/13/15
Reliance Standard Life Enrollment Application Bonnie Sprague 05/15/15
Summary Annual Report - Dental plan Bonnie Sprague 02/05/16
Summary Annual Report - Group Term life insurance plan Bonnie Sprague 02/05/16
Summary Annual Report - Health plan Bonnie Sprague 02/05/16
Summary Annual Report - Supplemental life insurance plan Bonnie Sprague 02/05/16
Summary Annual Report - Vision plan Bonnie Sprague 02/05/16
Supervision Agreement Bonnie Sprague 01/14/16
TicketsatWork Information Lillie Wiggins 09/03/15
Information Systems - America Back To Top
Adding an Access Code for a Network Printer Liam Barry 07/16/14
Centerstone IP Phone Reference Matt Skulley 11/28/12
CISCO Phone User Guide Matt Skulley 01/29/13
Cisco Quick Reference Matt Skulley 11/28/12
Cisco Voicemail Setup Instructions Matt Skulley 11/28/12
GHG FAQs Blake Biggs 02/06/18
GHG Time & Attendance Software Training Manual - Hourly Employees CSA-GHGAdmins@centerstone.org 01/08/16
GHG Time & Attendance Software Training Manual - Salary Employees CSA-GHGAdmins@centerstone.org 01/08/16
GHG Time & Attendance Software Training Manual - Supervisor User's Guide CSA-GHGAdmins@centerstone.org 01/08/16
Instructions for Installing a Network Printer on Windows 7 Liam Barry 04/02/12
Mileage Training for Employees CSA.BusinessApplications@centerstone.org 07/28/17
Mileage Training for Supervisors CSA.BusinessApplications@centerstone.org 07/28/17
Mileage Training Reports CSA.BusinessApplications@centerstone.org 07/28/17
New Employee Login Request Form Cody Lee 07/16/14
RightFax Cover Sheet Customization Bryan Lawrence 08/10/17
RightFax Product Suite Installation and Usage Bryan Lawrence 08/01/17
Intake - IN - Indiana Back To Top
Adult Confidential Clinical History Form 07/31/17
Adult Confidential Form - Spanish Michelle Sears 07/30/18
Advance Beneficiary Notice of Coverage (ABN) Form Michelle Sears 10/24/11
Annual Client's Rights Notification 03/17/10
ANSA/CANS Highlights FY15 Nikki Tumey 06/19/14
Anthem Coordination of Care Form Michelle Sears 09/19/17
Authorization for Psychotropic Medication Michelle Sears 02/28/12
Authorization to Release Information for Indiana Department of Child Services Michelle Sears 10/18/17
Cenpatico Coordination of Care Form Michelle Sears 01/03/11
Centerstone Recovery Works Referral Form Michelle Sears 11/18/15
Client Registration Form Michelle Sears 09/05/18
Client Rights and Resources Guide - English Michelle Sears 07/17/18
Client Rights and Resources Guide - Spanish Michelle Sears 04/03/14
Consent to Release Drug Testing Results Michelle Sears 08/05/15
Copay Sliding Scale Reference Chart Michelle Sears 11/30/18
DSC Enrollment Letter Nikki Tumey 06/19/14
Fee and Welcome Information Sheet Michelle Sears 05/03/18
HAP Letter - English Michelle Sears 07/01/11
HIPAA Client's Acknowledgement 03/17/10
Indiana Health Programs Income Eligibility Reference Sheet Michelle Sears 05/11/17
MD Wise Coordination of Care Form Michelle Sears 07/16/14
Medicaid Coordination of Care Form Tonya Shimkus 09/19/17
Medicare Secondary Payer Screening Form Michelle Sears 05/11/11
Patient Health Questionnaire (Adolescents) Michelle Sears 09/02/16
Patient Health Questionnaire (Adults) Michelle Sears 09/02/16
Payer Reference Chart Michelle Sears 11/30/18
Poverty Guidelines 2018 Nikki Tumey 08/27/18
Recovery Works Cheat Sheet Michelle Sears 11/18/15
Recovery Works - Explanation and Signature Sheet Michelle Sears 08/17/18
Recovery Works - Individualized Recovery Plan Michelle Sears 08/17/18
Registration Form - Spanish Michelle Sears 07/30/18
Release of Information - Spanish Michelle Sears 07/30/18
Supplemental Data Definitions FY15 Nikki Tumey 06/19/14
Supplemental Page FY15 Nikki Tumey 06/19/14
TB Questionnaire Adelaide Wetzel 12/02/14
Treatment Recommendation Checklist Sherry Hardesty 07/16/14
Tuberculosis Screening Form 07/16/14
Walk-In All Locations Susan Points 08/12/14
Youth Confidential Clinical History Form 04/30/10
Intake - TN - Tennessee Back To Top
Advance Care Plan (TN) Brad Nunn 07/27/16
Authorization for Release of Information Scott Valentine 03/01/10
Client Resource Guide Kathy Rogers 09/17/18
Declaration for Mental Health Treatment Scott Valentine 03/13/14
Form Approval Request Carol Draper 09/01/17
Initial Visit Packet Flyer Sallie Allen 11/19/09
Interpretive Summary Template Brad Wiles 11/05/18
PHQ9 (Depression screening tool for adults) Kathy Rogers 01/26/18
PHQ A (Depression screening tool for adolescents) Kathy Rogers 01/26/18
Request for Internet Access to Protected Health Information Scott Valentine 11/19/09
TennCare Kids Flyer, English Kathy Rogers 11/17/16
TennCare Kids Flyer, Spanish Kathy Rogers 11/17/16
Letterhead - FL - Florida Back To Top
Bradenton, 2020 26th Avenue East 01/19/17
Bradenton, 379 6th Avenue West 01/19/17
Bradenton, 391 6th Avenue West 01/25/17
Bradenton, 5214 4th Avenue Circle East 01/19/17
Sarasota, 4010 Sawyer Road 01/19/17
Letterhead - IL - Illinois Back To Top
Alton, 2615 Edwards Street 01/19/17
Carbondale, 200 North Emerald Lane 01/19/17
Carbondale, 2311 South Illinois Avenue 01/19/17
Marion, 1307 West Main Street 01/19/17
Marion, 3111 Williamson County Parkway 01/19/17
West Frankfort, 902 West Main Street 01/19/17
Letterhead - IN - Indiana Back To Top
Bedford, 1315 Hillcrest Road 01/19/17
Bloomington, 221 North Rogers Street 01/19/17
Bloomington, 645 South Rogers Street 01/19/17
Bloomington, 817 West First Street 01/19/17
Columbus, 2412 Indiana Avenue 01/19/17
Columbus, 720 North Marr Road 01/19/17
Connersville, 390 East Erie Street 01/19/17
Greencastle, 141 Martinsville Street 01/19/17
Greensburg, 1530 Commerce Park West Drive 01/19/17
Madison, 3008 North Bevcher Drive 01/19/17
Martinsville, 1175 Southview Drive 01/19/17
Muncie, 2809 West Goodman Avenue 01/19/17
Nashville, 91 West Mound Street - PO Box 550 01/19/17
New Castle, 3337 South State Road 3 01/19/17
North Vernon, 1260 East Buckeye Street 01/19/17
Richmond, 200 North 13th Street 01/19/17
Richmond, 54 South 15th Street 01/19/17
Richmond, 809 Dillon Drive 01/19/17
Richmond, 831 Dillon Drive 01/19/17
Rushville, 1400 North Cherry Street 01/19/17
Seymour, 1443 Corporate Way 01/19/17
Spencer, 35 Bob Babbs Drive 01/19/17
Union City, 224 North Columbia Street 01/19/17
Winchester, 325 South Oak Street - Suite 103 01/19/17
Letterhead - KY - Kentucky Back To Top
Lagrance, 2141 Spencer Court 01/19/17
Louisville, 101 West Muhammad Ali Boulevard 01/19/17
Louisville, 11001 Blurgrass Parkway – Suite 200 01/19/17
Louisville, 1900 South 7th Street – Entrance C 01/19/17
Louisville, 2105 Crums Lane 01/19/17
Louisville, 2210 Tucker Station Road 01/19/17
Louisville, 2225 West Broadway 01/19/17
Louisville, 2415 Rockford Lane 01/19/17
Louisville, 2650 West Broadway 01/19/17
Louisville, 2817 Del Rio Place – Suite 104 01/19/17
Louisville, 2817 Del Rio Place – Suite 109 01/19/17
Louisville, 3703 Taylorsville Road – Suite 102 01/19/17
Louisville, 3717 Taylorsville Road 01/19/17
Louisville, 4710 Champions Trace – 102 01/19/17
Louisville, 4710 Champions Trace – 104 01/19/17
Louisville, 4710 Champions Trace – 107 01/19/17
Louisville, 600 South Preston Street 01/19/17
Louisville, 708 Magazine Street 01/19/17
Louisville, 914 East Broadway 01/19/17
Louisville, 9702 Stonestreet Road, 110 01/19/17
Shelbyville, 231 Washington Street 01/19/17
Shelbyville, 250 Alpine Drive 01/19/17
Shepherdsville, 130 South Joe B. Hall Avenue 01/19/17
Taylorsville, 80 East Main Street – Suite 4 01/19/17
Letterhead - TN - Tennessee Back To Top
Chattanooga, 6110 Shallowford Road – Suite B 01/19/17
Clarksville, 1820 Memorial Circle 01/19/17
Clarksville, 404 Pageant Lane 01/19/17
Clarksville, 511 8th Street 01/19/17
Clarksville, 611 8th Street 01/19/17
Clarksville, 812 Greenwood Avenue 01/19/17
Clarksville, 901 Martin Street 06/29/18
Cleveland, 4160 North Ocoee Street 05/30/18
Columbia, 1222 Medical Center Drive 01/19/17
Columbia, 1600 Nashville Highway 01/19/17
Columbia, 211B Wayne Street 01/19/17
Columbia, 230 East James Campbell Boulevard - Suites 109 & 113 01/19/17
Columbia, 6011 Trotwood Avenue 01/19/17
Cookeville, 13 South Jefferson Ave - 71001 09/15/17
Cookeville, 606 East Spring Street - 71002 Rhonda DeVore 07/31/18
Dickson, 224 North Main Street 01/19/17
Dickson, 721 Highway 46 South 01/19/17
Estill Springs, 416 South Main Street 01/19/17
Fayetteville, 2241 Thornton Taylor Parkway 01/19/17
Gallatin, 332 Sumner Hall Drive 01/19/17
Hohenwald, 912 Summertown Highway 01/19/17
Lawrenceburg, 1090 Old Florence Road 11/05/18
Lewisburg, 1601 Nashville Highway 01/19/17
Madison, 620 South Gallatin Road 01/19/17
Nashville, 1921 Ransom Place 01/19/17
Nashville, 230 Venture Circle 01/19/17
Nashville, 2400 White Avenue 01/19/17
Nashville, 44 Vantage Way 01/19/17
Nashville, 44 Vantage Way - Suite 280 01/19/17
Nashville, 4525 Harding Pike – Suites 226, 236 & 236 01/19/17
Pulaski, 1002 Brindley Drive 01/19/17
Shelbyville, 1110 Woodbury Street 01/19/17
Shelbyville, 604 South Wall Street 01/19/17
Springfield, 713 Cheatham Street 01/19/17
Tullahoma, 1803 North Jackson Street 01/19/17
Tullahoma, 709 North Davidson Street 01/19/17
Wayensboro, 418 South Main Street 01/19/17
Managed Care - Tennessee Back To Top
Major Depressive Disorder: Annotated Bibliography 11/19/09
Schizophrenia Spectrum Disorders: Intensive Outpatient Program Care Guidelines 11/19/09
Schizophrenia Spectrum Disorders: Residential Care Guidelines 11/19/09
Medical Records - Indiana Back To Top
Acknowledgment Inquiry for Authorized Release of Mental Health Information 11/18/09
Authorization to Release Information for Indiana Department of Child Services Michelle Sears 10/18/17
Avatar Authorization to Release/Obtain Confidential Information Michelle Sears 06/06/17
Centerstone Telehealth Service Informed Consent Richard Prather 02/12/16
Certificate of Authentication of Protected Health Information 11/18/09
Certificate of No Record Michelle Sears 09/24/13
Clinical Abbreviations Michelle Sears 09/24/13
Consent for Taping Michelle Sears 09/24/13
Health Information Management Pamphlet Stephanie Spagnolo 04/28/16
Integrated Health Authorization Michelle Sears 07/26/17
Release of Information Cover Letter Sherry Hardesty 07/16/14
Release of Information for Payment Purposes Michelle Sears 01/25/16
Revocation of Authorization to Release/Obtain Confidential Information Michelle Sears 10/03/14
Medical Records / Health Information Management (HIM) - Tennessee Back To Top
Affidavit of Custodian of Medical Records Scott Valentine 11/18/09
Aid to Capacity Evaluation Scott Valentine 11/19/09
Approved Abbreviations for Clinical Notes Kathy Rogers 10/05/17
Authorization for Release of Information Form Carol Draper 04/18/17
Case Management/CTT Crisis Plan Scott Valentine 11/19/09
CenterNet batch coversheet for Data Imaging Services 03/20/17
Centerstone Telehealth Service Informed Consent Kathy Rogers 10/22/15
Certificate of Need for Emergency Involuntary Admission Kathy Rogers 07/16/18
Certificate of No Record Scott Valentine 11/19/09
Client Rights Kathy Rogers 03/14/17
Consent for Taping (Clinical Supervision) 11/19/09
Consent to Treatment Kathy Rogers 08/17/18
Intensive In-Home Program Accept Decline Form 07/10/14
Medication Disposal Form Scott Valentine 11/19/09
Medication Log Scott Valentine 11/19/09
Obtaining Proof of Decision-Making Authority Carol Draper 02/02/16
Quick Inventory of Depressive Symptomatology (QIDS) Ken Saefkow 11/18/09
Release of Information Flow Chart Carol Draper 06/12/17
Request for Internet Access to PHI Scott Valentine 11/18/09
Script for Client Requests for Medical Records Carol Draper 04/18/17
Surrogate Decision-maker Agreement Kathy Rogers 05/12/15
Unclaimed Medical Records - 2018 Carol Draper 11/20/17
Universal Povider Initiated Notice (Grier) Kathy Rogers 09/13/13
Medication Assisted Treatment - Tennessee Back To Top
Buprenorphine consent form Carol Draper 10/03/18
DEA Inspection Protocol Michael Reynolds 11/30/18
MAT Agreement to Participate Carol Draper 10/03/18
MAT contract Carol Draper 10/03/18
Substance use disorder agreement Carol Draper 10/03/18
Consent For Treatment With Psychotropic Medication Kathy Rogers 08/02/17
DCS Informed Consent for Psychotropic Medication Kathy Rogers 08/02/17
DCS Psychotropic Medication Evaluation Form Kathy Rogers 08/02/17
Instructions for Prescribing Medication for Children in DCS Custody Kathy Rogers 08/02/17
List of DCS Regional Child Health Nurses Kathy Rogers 08/02/17
List of DCS Regions/Counties Kathy Rogers 08/02/17
Miscellaneous - IN - Indiana Back To Top
2019 Holiday Closing — Martin Luther King Day - version 1 01/08/19
2019 Holiday Closing — Martin Luther King Day - version 2 01/08/19
CANS/ANSA FY 14 Supplemental Page (condensed) Jenny Hahn 07/25/13
Children First 2017 Certificate Susan Points 12/21/16
Door Plate Order Form 07/16/14
Emergency Preparedness Report Form Maria Nehrt 11/30/18
Employee Exit Attestation Richard Prather 09/04/13
First Aid Inspection Sheet 07/16/14
Front Office Phone and Fax Extensions for Central and West Regions Maria Nehrt 07/16/14
Healthy Indiana Plan 2.0 Overview Stephanie Spagnolo 04/06/15
Infection Control Reporting Form Emily Ivancic, RN 09/04/12
Marketplace Health Insurance Application Stephanie Spagnolo 01/28/15
Marketplace Health Insurance Application Instructions Stephanie Spagnolo 01/28/15
Marketplace Resource Guide Stephanie Spagnolo 01/28/15
Vehicle Accident Reporting Maria Nehrt 07/16/14
Miscellaneous - TN - Tennessee Back To Top
Attorney Letter for Disability Appeal Evaluation Rebecca Marshall 06/27/14
Clinical Supervision Documentation Form Kathleen Rogers 09/20/16
Meeting Room Request Form - Hayes Center Gwen Watts 11/19/09
Meeting Room Request Form - Luton 11/19/09
Risk Assessment and Disposition Form Sallie Allen 11/19/09
Screening of Clients for Psychiatric Services Only Dan Mansfield 11/06/17
TennCare Redetermination Appeal Form 11/19/09
Tennessee Department of Health Notifiable Disease Form 11/19/09
Unified Care Plan - Excel 11/19/09
Unified Care Plan Goals and Objectives - Paper 11/19/09
Unified Care Plan - Paper 11/19/09
Non-English Forms - IN - Indiana Back To Top
Arabic: Notice of Privacy Practice Scott Valentine 01/27/14
Spanish: Acknowledgement of Receipt of Privacy Notice Scott Valentine 01/27/14
Spanish: Application Inquiry 01/27/14
Spanish: CR102-99 Medical History DL 01/27/14
Spanish: CR104-99 Confidential Application LMC 01/27/14
Spanish: CR121-99 Client Rights & Consent to Treatment 01/27/14
Spanish: CR151-00 Release of Information 01/27/14
Spanish: HAP Letter Michelle Sears 01/27/14
Spanish: Revocation of Consent 01/27/14
Non-English Forms - TN - Tennessee Back To Top
Arabic: Notice of Privacy Practice Scott Valentine 01/27/14
Spanish: Adding a Pathway to your Treatment Plan Kathy Rogers 12/02/15
Spanish: Adding a Pathway to your Treatment Plan minors Kathy Rogers 12/02/15
Spanish: Authorization for Release of Information Carol Draper 04/18/17
Spanish: Case Management Accept Decline Form Scott Valentine 01/27/14
Spanish: Consent For Treatment With Psychotropic Medication Scott Valentine 01/27/14
Spanish: Consent To Treatment Scott Valentine 01/27/14
Spanish: Notice of Privacy Practices Scott Valentine 01/27/14
Spanish: Pathway Caring Letter Kathy Rogers 08/14/15
Spanish: Request for an Accounting of Disclosures Scott Valentine 01/27/14
Spanish: Request for Confidential Communications Form Scott Valentine 01/27/14
Spanish: Request for Restriction on Use/Disclosure of Protected Health Information Scott Valentine 01/27/14
Spanish: Request to Amend Protected Health Information Scott Valentine 01/27/14
Spanish: Revocation of Authorization for Centerstone to Use or Disclose Health Information Scott Valentine 01/27/14
Open Access Scheduling - TN - Tennessee Back To Top
Open Access Scheduling - Announcement Document Kathy Rogers 08/21/18
Open Access Scheduling - Frequently Asked Questions for Clients Kathy Rogers 09/05/18
Open Access Scheduling - Frequently Asked Questions for Staff Kathy Rogers 08/21/18
Open Access Scheduling - Guidelines Kathy Rogers 08/21/18
Payroll Services - IL - Illinois Back To Top
2017 Illinois W4 Form Michelle Bacher 09/28/17
2018 Bi-Weekly Payroll Calendar Michelle Bacher 12/08/17
2018 Semi Monthly Payroll Calendar Michelle Bacher 12/08/17
2018 W4 For Federal Tax Exemptions Michelle Bacher 02/28/18
AP/ Payroll Direct Deposit Form Michelle Bacher 09/28/17
GHG Correction Form Michelle Bacher 09/28/17
Personal Cell Phone Reimbursement Authorization Michelle Bacher 09/28/17
Supplemental Pay Form Michelle Bacher 09/28/17
Understanding Your Pay Michelle Bacher 07/02/18
Payroll Services - IN - Indiana Back To Top
2017 IN WH-4 Form Michelle Bacher 09/28/17
2018 Semi Monthly Payroll Calendar Michelle Bacher 12/08/17
2018 W4 For Federal Tax Exemptions Michelle Bacher 02/28/18
AP/ Payroll Direct Deposit Form Michelle Bacher 09/28/17
GHG Correction Form Michelle Bacher 09/28/17
Personal Cell Phone Reimbursement Authorization Michelle Bacher 09/28/17
Understanding Your Pay Michelle Bacher 07/02/18
Payroll Services - TN - Tennessee Back To Top
2018 Semi Monthly Payroll Calendar Michelle Bacher 12/08/17
2018 W4 For Federal Tax Exemptions Michelle Bacher 02/28/18
AP/ Payroll Direct Deposit Form Michelle Bacher 09/28/17
GHG Correction Form Michelle Bacher 09/28/17
Personal Cell Phone Reimbursement Authorization Michelle Bacher 09/28/17
Supplemental Pay Form Michelle Bacher 09/28/17
Understanding Your Pay Michelle Bacher 07/02/18
Privacy and Security - IN - Indiana Back To Top
Confidentiality Agreement Christi Brown 07/17/14
Consent for Video/Audio Recording Form 01/25/19
Denial of Patient Request for Amendment to Protected Health Information Michelle Sears 10/21/13
List of Approved Software Applications 01/25/19
Non-Business Associate Vendor Confidentiality Agreement Michelle Sears 07/17/14
Notice of Privacy Practices for Protected Health Information Michelle Sears 07/17/14
Request for Confidential Communications Form Michelle Sears 10/21/13
Request to Amend Protected Health Information Michelle Sears 10/21/13
Visitor Sign-In Sheet Michelle Sears 07/17/14
Withdrawal of Agreement for Text Communication Michelle Sears 10/21/13
Privacy and Security - TN - Tennessee Back To Top
Centerstone Notice Of Privacy Practices Scott Valentine 07/17/14
Client Right to Accounting of Disclosures of PHI Scott Valentine 08/23/17
Consent for Video/Audio Recording Form Scott Valentine 01/24/19
Denial of Request for Amendment to Protected Health Information Scott Valentine 11/19/09
Health Link Level of Care Form Carol Draper 04/18/17
List of Approved Software Applications 01/25/19
Non-Business Associate Vendor Confidentiality Agreement Scott Valentine 07/17/14
Request for Confidential Communications Scott Valentine 11/19/09
Request for Restriction of Use and Disclosure Scott Valentine 08/23/17
Request to Amend Protected Health Information Scott Valentine 11/19/09
Revocation of Authorization to Disclose Health Information Scott Valentine 11/19/09
Text Messaging Authorization Form Karen Keene 12/18/12
Visitor Sign-In Sheet Karen Keene 07/17/14
Withdrawal of Agreement for Text Communication Karen Keene 12/18/12
Psychiatric Documents - Tennessee Back To Top
Info Sheet About Laboratory Studies Kathy Rogers 07/11/18
Quality Improvement - IN - Indiana Back To Top
Approved Abbreviations List Rona Krueger 02/27/13
Client Complaint Form Kristina Dale 02/14/13
Fillable Incident Report Form - Indiana Jean Tappe 05/04/18
Request for Continuing Education Units Rona Krueger 03/18/15
Types of Incidents for Reporting-Outpatient-Community Jeane Tappe 02/27/18
Quality Improvement - TN - Tennessee Back To Top
Adverse Occurrence Clinical Review Form Kathy Rogers 06/07/18
Adverse Occurrences and Incident Reporting Kathy Rogers 11/05/18
Centerstone Complaint Process for Posting in Waiting Rooms 12/04/09
Complaint Form for Lobby 02/14/13
EHR Change Request Form Camille Ardent 06/26/17
Recommendation for Termination of Services Kay Brown 04/01/13
Revised Clinical Review Form (Word version) Kathy Rogers 04/26/18
TennCare Transportation Contact Info Kathy Rogers 01/09/19
Termination Letter Kathy Rogers 08/03/16
Title VI Complaint Form Sherry Harrison 07/02/14
Suicide Prevention Pathway - Tennessee Back To Top
Adding a Pathway to Your Treatment Plan - Education Sheet Kathy Rogers 09/17/15
Crisis Plan for Suicide Pathway Enrollees Lisa Eggebeen 09/16/15
Safety Sweep Checklist Lisa Eggebeen 09/16/15
Spanish: Adding a Pathway to your Treatment Plan Kathy Rogers 12/02/15
Spanish: Adding a Pathway to your Treatment Plan minors Kathy Rogers 12/02/15
Spanish: Suicide Pathway Caring Letter Kathy Rogers 12/02/15
Suicide Pathway Caring Letter Kathy Rogers 03/16/17
Suicide Pathway Checklist Andy Lawrence 02/09/18
Suicide Pathway Documentation Reminders Kathy Rogers 06/19/15
Zero Suicide - Frequently Asked Questions Kathy Rogers 08/31/18
West Region - Intake - Indiana Back To Top
Addictions Walk-In Checklist Fees Estimation 11/18/09
City of Bedford Intake 11/18/09
CR116-99 Teen Screen 11/18/09
West Region - Miscellaneous - Indiana Back To Top
72-Hour Hold Emergency Detention 11/18/09
ACT Admission Form 11/18/09
Child & Adolescent Transportation Service Log 11/18/09
Copier/Fax Service Request 11/18/09
Hospital Consult Request 11/18/09
Order Continuing Regular Commitment without Hearing 11/18/09
Problematic Medications Letter 11/18/09
Report to Request Continuing Commitment without Hearing 11/18/09
Report to Request Continuing of Temporary Commitment 11/18/09
Request for Superintendent's Authorization to Transfer Involuntarily Committed Patient 11/18/09
Request for Transport 07/17/14
Scholarship Application for Clients 01/13/10
Substance Abuse Education Class (SAEC) Contract 11/18/09
Temporary to Regular Commitment Report Morgan County 11/18/09
Transfer of Commitment 11/18/09
Transportation Log 11/18/09
Treatment Plan Summary 11/18/09
West Region - Releases - Indiana Back To Top
Confidentiality Agreement for Auditors & Visitor 11/18/09
CR122-99 Authorization of Audio and Video Taping of Therapy Sessions 11/18/09
CR210-94 Waiver & Release of Liability 11/18/09
Mental Health Treatment Review Team Release 11/18/09