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Blank 508 From Nc Dwi Services PDF Form

The 508 Form NC DWI Services is an essential document utilized in the assessment and monitoring of individuals involved in Driving While Intoxicated (DWI) cases in North Carolina. This form serves to ensure compliance with state regulations and to document the necessary evaluations and findings related to a client's treatment and progress. To begin the process of assessment, please fill out the form by clicking the button below.

Article Guide

The 508 Form from North Carolina DWI Services plays a critical role in the assessment and management of individuals undergoing evaluations related to Driving While Impaired (DWI) offenses. This form encompasses several essential sections, each designed to ensure compliance with state regulations and to facilitate effective monitoring of clients. It begins with a verification of staff credentials, ensuring that only qualified professionals conduct assessments. The clinical assessment section requires evidence of a diagnosis according to the DSM-IV criteria, as well as documentation of the client’s consent for information release. Additionally, the form mandates that a Certificate of Completion be submitted promptly to the state office, reflecting the provider's adherence to established timelines. For clients assessed under the Driving While License Revoked (DWLR) category, specific criteria must be met, including documentation of remission status and treatment referrals. Areas where compliance is not achieved must be noted, leading to corrective action plans as necessary. This structured approach not only safeguards the integrity of the assessment process but also aims to enhance the overall effectiveness of DWI services in North Carolina.

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NC DIVISION OF MH/DD/SAS

2010-2011 DWI MONITORING TOOL 2 – ASSESSMENT/E508 SYSTEM

Areas deemed not met are documented on the Review Findings and Exit Form. Forms are signed by the Provider indicating acknowledge of findings that result in Plan(s) of Correction as required by Division Policy ACC002 and the Office of DWI Services.

PROVIDER/FACILITY NAME:	PROVIDER CODE:

CLIENT NAME:	RECORD #:

ASSESSMENT DATE:	CONTROL #:

SYSTEM COMPLIANCE FOR ASSESSMENT/CERTIFICATE OF COMPLETION

0 = NOT MET; 1 = MET; 9 = NOT APPLICABLE

RATING

Check √ if this is a Driving While License Revoked (DWLR) Assessment □

SECTION I: STAFF CREDENTIALS/APPROVALS – ASSESEMENT PROVIDERS

In accordance with 10A NCAC 27G.0104

1. Staff is qualified to complete assessments as verified by NCSAPPB.

SECTION II: CLINICAL ASSESSMENT

2. Evidence of DSM-IV diagnosis is present as determined by clinical assessment.

DSM IV Codes: Alcohol Dependence 303.90:	_____
Alcohol Abuse 305.00:	_____
Other: Indicate Disorder or Code: _____
ADETs: No Diagnosis	_____

NOTE: FOR DWLR ASSESSEENTS: Enter “9” and complete Section IV.

3.Evidence of ASAM Patient Criteria is present as determined by clinical assessment.

4.Client Signature is present indicating they were given an updated list of all DWI Providers within their service area.

5.The client signature is present on the Consent Form for Release of Information and includes the various agencies for communicating and reporting findings. (10A NCAC 27G .3807 (d).

SECTION III: DOCUMENTATION: CERTIFICATE OF COMPLETION – e508 SYSTEM

In accordance with Division Policy 0108 eff. 2/1/2008 and Division Policy 1207 eff. 12/1/2007

6.There is evidence that Certificate of Completion was submitted within two (2) weeks of the assessment date.

Assessment Date:_____________ Date Sent to State Office: ____________

7.There is evidence that the provider has managed the e508 system to ensure every step of the process has been completed for the assessment. (Exceptions Noted).

8.The provider has made efforts to resolve holds/rejects within the e508 system that are associated with this client record. (Exceptions Noted).

2010-2011 DWI Monitoring Tool 2

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NC DIVISION OF MH/DD/SAS

2010-2011 DWI MONITORING TOOL 2 – ASSESSMENT/E508 SYSTEM

9.Certificate of Completion Form which indicates date sent to State Office has been signed by professional staff and placed within client file. (Date Sent to State Office does not indicate <blank>).

SECTION IV: DRIVING WHILE LICENSE REVOKED – DWLR

In accordance with Statutory Reference G.S. 20-28

10.Diagnosis was based on clinical assessment that indicates:

a.Early Full Remission _____

b.Sustained Remission _____

c. Partial Remission	_____
d. Other:	_____

11.Client was referred to treatment based on diagnosis of partial remission.

OVERALL

10.

11.

COMMENTS: (Use Additional Comments Sheet as needed)

Findings require corrective actions: (Circle) YES

Auditor Instructions

Use Comments section to indicate areas of noncompliance that result in a Plan of

Correction (POC) and provide details to support findings

Reviewer Signature:

Date:

2010-2011 DWI Monitoring Tool 2

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NC DIVISION OF MH/DD/SAS

2010-2011 DWI MONITORING TOOL 2 – ASSESSMENT/E508 SYSTEM

ADDITIONAL COMMENTS

_________________________________________________________________________________________________________

2010-2011 DWI Monitoring Tool 2

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NC DIVISION OF MH/DD/SAS

2010-2011 DWI MONITORING TOOL 2 – ASSESSMENT/E508 SYSTEM

ADDITIONAL COMMENTS

_________________________________________________________________________________________________________

2010-2011 DWI Monitoring Tool 2

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➤ PDF File

Form Specifications

Fact Name	Details
Governing Law	The form is governed by 10A NCAC 27G.0104 and G.S. 20-28.
Provider Acknowledgment	Providers must sign forms to acknowledge findings that lead to corrective plans.
Assessment Date	The assessment date is critical for compliance, particularly for submission timelines.
Certificate of Completion	A Certificate of Completion must be submitted within two weeks of the assessment date.
Client Signature	Client signatures are required on both the consent form and the updated provider list.
DWLR Assessments	For Driving While License Revoked (DWLR) assessments, specific codes must be entered.
Documentation Requirements	All findings of noncompliance must be documented, and corrective actions may be necessary.

508 From Nc Dwi Services: Usage Guidelines

Filling out the 508 Form for NC DWI Services requires careful attention to detail. After completing the form, it will be reviewed to ensure compliance with the necessary regulations and policies. This process is essential for maintaining accurate records and facilitating the next steps in the assessment and treatment process.

Begin by entering the Provider/Facility Name and Provider Code at the top of the form.
Fill in the Client Name and Record # to identify the individual being assessed.
Specify the Assessment Date and Control # to track the assessment timeline.
Indicate whether this assessment is for a Driving While License Revoked (DWLR) by checking the appropriate box.
In Section I, confirm that the staff completing the assessment is qualified as verified by NCSAPPB.
In Section II, document the DSM-IV diagnosis codes for the client, including Alcohol Dependence, Alcohol Abuse, or other disorders, as applicable.
Ensure evidence of ASAM Patient Criteria is present based on the clinical assessment.
Collect the client’s signature to confirm they received an updated list of all DWI providers in their area.
Obtain the client’s signature on the Consent Form for Release of Information, ensuring it includes all necessary agencies.
In Section III, verify that the Certificate of Completion was submitted within two weeks of the assessment date.
Check that the provider has managed the e508 system effectively, noting any exceptions.
Document any efforts made to resolve holds or rejects within the e508 system related to this client.
Ensure the Certificate of Completion Form is signed by professional staff and included in the client file.
In Section IV, assess the clinical diagnosis based on the assessment and indicate if it falls under early, sustained, or partial remission.
Complete the comments section to provide any additional notes or findings that require corrective actions.
Finally, include the auditor's signature and date at the bottom of the form.

Your Questions, Answered

What is the 508 Form for NC DWI Services?

The 508 Form is a DWI Monitoring Tool used by the North Carolina Division of Mental Health, Developmental Disabilities, and Substance Abuse Services. It is designed to assess individuals undergoing DWI evaluations and treatments, ensuring compliance with state regulations.

Who needs to fill out the 508 Form?

The form must be completed by certified assessment providers who evaluate clients with DWI offenses. This includes licensed professionals who have the necessary credentials to conduct assessments as specified by North Carolina regulations.

What information is required on the 508 Form?

Essential details include the provider's name and code, client name, record number, assessment date, and control number. The form also requires clinical assessment findings, client signatures, and documentation of compliance with the e508 system.

How is the assessment rated on the 508 Form?

Assessments are rated on a scale of 0 to 1, where 0 indicates "not met," and 1 indicates "met." A rating of 9 signifies that a section is not applicable. Providers must check off the appropriate ratings for each section of the assessment.

What happens if areas are deemed not met?

If any areas are not met, they are documented on the Review Findings and Exit Form. The provider must sign this form, acknowledging the findings, which may lead to the development of a Plan of Correction as required by state policy.

What is the significance of the Certificate of Completion?

The Certificate of Completion confirms that the assessment process has been finalized and submitted within two weeks of the assessment date. This certificate must be signed by professional staff and included in the client's file for record-keeping purposes.

What is the role of the e508 system in this process?

The e508 system manages the assessment process. Providers must ensure that all steps are completed and that any holds or rejects associated with the client record are addressed. This system is crucial for maintaining compliance with state regulations.

What is the DWLR section of the form?

The Driving While License Revoked (DWLR) section assesses clients specifically for DWI offenses related to license revocation. It includes additional criteria for diagnosis and treatment referrals based on the client's status.

What should be done if corrective actions are required?

If findings indicate the need for corrective actions, the provider must circle "YES" or "NO" on the form. Detailed comments should be provided to support any noncompliance issues, and a Plan of Correction may be necessary.

Where can I find more information about the 508 Form?

For more information, you can contact the North Carolina Division of Mental Health, Developmental Disabilities, and Substance Abuse Services or visit their official website. They provide resources and guidance related to DWI assessments and the use of the 508 Form.

Common mistakes

Incomplete Information: Many individuals fail to fill out all required fields, such as the provider code or assessment date. Missing this information can lead to processing delays.
Incorrect Client Name: Entering the wrong client name can result in confusion and misidentification. It is crucial to ensure that the name matches official documents.
Misunderstanding DSM-IV Codes: Some users mistakenly enter incorrect DSM-IV codes or fail to provide a diagnosis altogether. Accurate coding is essential for proper assessment and treatment planning.
Failure to Obtain Client Signature: Not obtaining a client signature on the consent form for the release of information can lead to compliance issues. This signature is necessary for sharing assessment results.
Neglecting to Document Certificate of Completion: Some providers forget to submit the Certificate of Completion within the required two-week timeframe. This oversight can result in administrative complications.
Ignoring Holds or Rejects: Failing to address holds or rejects in the e508 system can impede progress. Providers should actively manage these issues to ensure timely processing.
Inaccurate Assessment Ratings: Some users may incorrectly rate compliance areas. Ratings should reflect a true assessment of whether criteria have been met or not.
Omitting Comments: Not using the comments section to clarify areas of noncompliance can lead to misunderstandings. Providing detailed explanations is important for transparency.

Documents used along the form

When working with the 508 Form from NC DWI Services, several other forms and documents often accompany it. Each of these documents serves a specific purpose in the assessment and monitoring process, ensuring that all necessary information is collected and communicated effectively.

Review Findings and Exit Form: This form documents areas that did not meet compliance during the assessment. It is crucial for tracking required corrective actions and ensuring accountability.
Plan of Correction (POC): When non-compliance is identified, a POC outlines the steps the provider will take to address these issues. This document is vital for demonstrating commitment to improvement.
Certificate of Completion: This certificate confirms that the client has completed the necessary assessments and is submitted to the state office within the required timeframe. It is a key document for compliance.
Consent Form for Release of Information: This form ensures that the client agrees to share their assessment results with relevant agencies. It protects client confidentiality while facilitating communication among providers.
Clinical Assessment Documentation: This includes notes and evidence from the clinical assessment, such as DSM-IV diagnoses. It provides a detailed understanding of the client’s condition and treatment needs.
Additional Comments Sheet: Used for any extra notes or observations during the assessment process, this sheet allows for comprehensive documentation of the client’s situation and progress.

These documents collectively support the assessment process, ensuring that all parties involved have the necessary information to make informed decisions regarding treatment and compliance. Keeping track of these forms is essential for maintaining a smooth workflow and achieving successful outcomes for clients.

Similar forms

Assessment Form for Substance Abuse Treatment: This document collects information on a client's substance use and mental health history, similar to the DWI Monitoring Tool. Both forms aim to ensure clients receive appropriate treatment based on their specific needs.
Consent for Release of Information: Like the DWI form, this document requires a client's signature to share their information with other agencies. This process is crucial for coordinating care and ensuring compliance with legal requirements.
Certificate of Completion: Both documents include a certificate that verifies the completion of required assessments or treatment. This serves as proof for regulatory compliance and helps track a client's progress.
Plan of Correction Form: This form outlines corrective actions needed when compliance issues arise. Similar to the DWI Monitoring Tool, it ensures that providers address any deficiencies in care or documentation.
Review Findings and Exit Form: This document summarizes the results of an assessment, much like the DWI Monitoring Tool. It highlights areas of noncompliance and requires acknowledgment from the provider.
Client Treatment Plan: Both documents involve creating a plan tailored to the client's needs based on assessment results. This ensures that clients receive personalized and effective care.
Clinical Assessment Report: Similar to the DWI Monitoring Tool, this report provides a detailed evaluation of a client's mental health and substance use, guiding treatment decisions.
Referral Form for Treatment Services: This document refers clients to appropriate treatment options, akin to the recommendations made in the DWI Monitoring Tool based on assessment findings.
Follow-Up Assessment Form: Like the DWI Monitoring Tool, this form is used to evaluate a client's progress after treatment. It helps determine if further intervention is necessary.

Dos and Don'ts

When filling out the 508 Form for NC DWI Services, it is crucial to follow certain guidelines to ensure accuracy and compliance. Below is a list of things to do and avoid.

Do ensure all client information is accurately filled out, including names and identification numbers.
Do check that all required signatures are present before submission.
Do submit the Certificate of Completion within two weeks of the assessment date.
Do verify that the assessment meets the necessary clinical criteria outlined in the guidelines.
Do document any noncompliance issues and outline corrective actions clearly.
Don't leave any sections blank unless specifically instructed to do so.
Don't submit the form without reviewing it for errors or missing information.

Misconceptions

Misconception 1: The 508 Form is only for clients with a DWI.

This form is often misunderstood as applicable solely to those with a Driving While Intoxicated (DWI) charge. In reality, it also includes assessments for those with a Driving While License Revoked (DWLR) status, ensuring a broader scope of evaluation.

Misconception 2: All assessments must result in a treatment recommendation.

Some believe that every assessment conducted using the 508 Form will automatically lead to a treatment plan. However, the assessment may conclude that no treatment is necessary, especially if the client is found to be in remission or has no diagnosis.

Misconception 3: The form is only relevant during the assessment period.

Many think the 508 Form is only important at the time of assessment. In fact, it plays a crucial role throughout the entire process, including documentation of findings and any necessary corrective actions that may arise later.

Misconception 4: The e508 system is optional for providers.

Some providers may believe that managing the e508 system is optional. This is not true. Compliance with the e508 system is essential, as it ensures that all steps of the assessment process are properly documented and completed.

Key takeaways

Ensure all sections of the 508 Form are completed accurately. Missing information can lead to delays or complications in processing.
Obtain necessary signatures from both the provider and the client. This includes the Consent Form for Release of Information and acknowledgment of findings.
Submit the Certificate of Completion within two weeks of the assessment date. Timely submission is crucial for compliance.
Document any areas of noncompliance clearly. Use the comments section to detail findings that require corrective actions.