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Provider Resources


Billing form for the Mental Health/Intellectual Disabilities/Early Intervention programs.

MH/ID 17 Certification Statment
This Certification Statement must be signed by the CEO or other responsible supervisory official of an agency and is to be submitted with the MH/ID17 fiscal form either as a separate attached page or photocopied on the backside of the MH/ID 17 form. It is not to be signed by the person completing the MH/ID 17 invoice.

MH/ID 17 Instructions

MH/ID Roster of Personnel Form 15-A
Agencies that are program funded are required to attach this form to the monthly billing form (MH/ID 17) to provide the detail for wage and salary expenses.

MH/ID Schedule of Equipment Purchases Form 19
Agencies that are program funded must complete this form and attach it to the monthly invoice (MH/ID 17) to provide the details of any equipment purchased by MH/ID funds.

MH/ID Fiscal Regulations (Chapter 4300)

Personnel Action Plan

Beaver County Personnel Action Plan Job Descriptions
The Beaver County Personnel Action Plan (PAP) is to be used by agencies funded by the Beaver County MH/ID Program through program funding and is also the allowable cost standard for programs that are fee for service where the BCBH Office negotiates the fee. It is not applicable to programs where the rate is established by the PA Department of Public Welfare (DPW) or established by Value Behavioral Health (VBH) for Health Choices programs.

Personnel Action Plan Guidelines
These guidelines are to be followed by all MH/ID agencies funded through the Beaver County Behavioral Health Office (BCBH) that are funded through program funding or by fee for service where the fee is negotiated through the BCBH Office.

Request for Position Approval Form
This form must be completed for all personnel funded through the Beaver County Behavioral Health Office for all MH/ID agencies that have programs that are program funded.

Personnel Data Summary Form
This personal data form is to be complete by all program funded programs for all staff funded by the Beaver County Behavioral Health Office. An agency's application form containing the same date may be substituted.

Job Description Form
This form must be completed for the personnel of all agencies funded through program funding by the Beaver County Behavioral Health Office and submitted with the Request for Position Approval form.

Contract Amendment

Contract Amendment - Allocation Increase

This amendment is used to increase a provider's allocation during a fiscal year. It can also be used when the rates change in conjunction with an allocation increase.

Contract Amendment - Rate Change

This amendment is used whenever the fee-for-service rate(s) need to be revised during the fiscal year when there is no change in the allocation.

Contract Amendment - Reallocation

This amendment is used when whenever a provider’s allocations to be reallocated from one program to another with no change in the original allocation.

Instructions to Complete the Contract Amendments

These are the instructions to complete the contract amendments for 1) allocation increase, 2) allocation decrease, 3) rate change and 4) allocation redistribution.


Provider Billing Codes
Table of provider programs with the designated cost centers, Accufund Code, County Code and Base Service Code

Exhibit D - Contract Budget Form
Budget form to be attached to MH/ID contracts and amendments.

Maximum Rates of State Participation for Employee Benefits, effective July1,2017
This DHS Administrative Bulletin defines the maximum percentage rate for employee benefits.

Maximum Rates for State Participation for Mileage Reimbursement Allowance for Personal Automobiles
This DHS Bulletin sets the maximum rates for the mileage reimbursement allowance for personal automobiles.

Maximum Rates for Lodging and Subsistence
This DHS Administrative Bulletin defines the maximum rates of reimbursement for lodging and subsistence when conducting official business for the county program.