Follow the steps to complete the self-assessment worksheet online.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Enter the provider name in the designated field at the top of the worksheet. This should be the name of the facility or organization providing services.
3. Fill in the OASAS provider number, which is essential for identification within the system.
4. Select the service type by checking either 'Part 822 Chemical Dependence Outpatient Clinic' or 'Part 822.9 Chemical Dependence Outpatient Rehabilitation' based on the services offered.
5. Input the total score and sample size to calculate the deficiency rate, which is important for evaluating your service quality.
6. For each Medicaid recipient, fill in their Medicaid ID number and patient ID number, along with service-related dates and evaluations as prompted in the admission and treatment plan sections.
7. In the treatment plan section, respond to each prompt (e.g., 'Evaluation Assessment', 'Admission Criteria') with 'Y' for Yes or 'N' for No, ensuring that your responses reflect compliance with necessary guidelines.
8. For progress notes, continue answering each section as indicated, making sure all information is comprehensive and accurate.
9. After completing all sections of the form, review your entries for accuracy, then save changes, and use the options available to download, print, or share the completed form.

Complete your documents online today for a streamlined billing assessment process.