Departmental Forms

Clinical Practice (CLP)
CLP_CODES Episode Opening and Closing Codes
CLP001 Client Payment Agreement
CLP002 Client Episode Summary (CSI)
CLP003_E Initial Contact Form
CLP003_S Initial Contact Form (Spanish)
CLP004 CSI Periodic Data
CLP005 Adult Clinical Assessment (A-1)
CLP006 Universal Charge Data Invoice (CDI) Revised!
CLP009 Charge Data Invoice (JJOP)
CLP010 Charge Data Correction Invoice
CLP012 Client Resource Evaluation
CLP013 Adult Psychiatric Evaluation (Fillable) Revised!
CLP013 Adult Psychiatric Evaluation (Printable) Revised!
CLP014 Child/Adolescent Psychiatric Evaluation and Update Revised!
CLP015 Child/Adolescent Clinical Assessment
CLP015-1 Child/Adolescent Clinical Assessment-CANS-SB Revised!
CLP016_E Physical Assessment
CLP016_S Physical Assessment (Spanish)
CLP017 Client Recovery Evaluation (Annual)
CLP018 Request to Waive Consumer’s Responsibility to Pay for Medications
CLP019 Care Necessity
CLP020 Psychological Testing Referral
CLP021 Healthy Homes Screening/Assessment
CLP022 Diagnosis Revised!
CLP024_E Client Recovery Plan/ISSP
CLP024_S Client Recovery Plan/ISSP (Spanish)
CLP025 Discharge Summary
CLP026 Abnormal Involuntary Movement Scale
CLP027 Interdisciplinary Notes
CLP028 Service Team Actions
CLP029_E Caregiver’s Authorization Affidavit
CLP029_S Caregiver’s Authorization Affidavit (Spanish)
CLP030 Request for Verification of Veterans Status for Mental Health and/or Substance Abuse Services
CLP031 Consent and Authorization to Exchange Confidential Information for Veterans Status
CLP035_E Medication Support Services Plan
CLP035_S Medication Support Services Plan (Spanish)
CLP043 HOST Care Plan Revised!
CLP044 Interdisciplinary Care Team (ICT) Referral Form New!
CLP0818 Policies Regarding Authorization and Designation Pursuant to the Lanterman-Petris-Short (LPS) Act Revised!
Prevention and Early Intervention (PEI)
Quality Management (QM)
QM001 Chart Audit Tool
QM005 Annual Psychiatric Assessment Review Form Revised!
QM018 Interdisciplinary Care Team (ICT) Referral Form New!
QM018_1 Guidelines for Completing Referral Summary for Referral to Managed Care Plan (MCP) Attachment I New!
QM020_E Tier Transition Letter Attachment II New!
QM020_S Tier Transition Letter Attachment II (Spanish) New!
QM044 Change Order Request Routing Slip Revised!
QM045 Mode of Service/Procedure Code Change Form
QM046 State Pre-Audit Chart Review Audit Tool
QM047_E Change of Provider Request Form Revised!
QM047_S Change of Provider Request Form (Spanish) Revised!
QM048_E Request for Second Opinion
QM048_S Request for Second Opinion (Spanish)
QM049 Mental Health and Alcohol and Drug Services Agency Evaluation
QM050_E Grievance Form Revised!
QM050_S Grievance Form (Spanish) Revised!
QM051_E Action Appeal Form Revised!
QM051_S Action Appeal Form (Spanish) Revised!
QM052 Quality Assurance Review of Unexpected Deaths
QM053 Unusual Occurrence/Incident Report
QM054 Clinic Supervisor Chart Audits
QM055 Program Manager Chart Audits
QM056 Quality Assurance Audit At Annual Point
QM057 Medication Monitoring Questionnaire
QM058_E Notice of Adverse Benefit Determination (Denial of Services: NOABD-A) Revised!
QM058_S Notice of Action (Assessment: NOA-A) (Spanish)  Revised!
QM059_E Notice of Adverse Benefit Determination (Previously-Authorized
Service Change: NOABD-B)
Revised!
QM059_S Notice of Action (NOA-B) (Spanish) Revised!
QM060_E Notice of Adverse Benefit Determination (Post-Service Denial of Payment: NOABD-C) Revised!
QM060_S Notice of Action (Post-Service Denial of Payment: NOA-C) (Spanish)  Revised!
QM061_E Notice of Adverse Benefit Determination (Lack of Timely Service: NOABD-D) Revised!
QM061_S Notice of Action (Lack of Timely Service: NOA-D) (Spanish)  Revised!
QM062_E Notice of Adverse Benefit Determination (Delay in Grievance/Appeal Processing: NOABD-E) Revised!
QM062_S Notice of Action (Delay in Grievance/Appeal Processing: NOA-E) (Spanish)  Revised!
QM063 MHS902 Clinic Log
QM064 DBH Research Proposal/Application
QM065 Table of Contents
QM066 Research Application Face Sheet
QM067 Statement of Agreement Between Research Applicant and the Department of Behavioral Health
QM068 Resources, Risks, and Support Form
QM069 Documentation of Informed Consent
QM070 HIPAA Compliance Assurance
QM071 Application Submission Checklist
QM072 Review and Approval Tracking Form
QM073 Reporting Unit Set-Up Form
QM074 Medi-Cal Certification Checklist
QM075 Mental Health Plan (MHP) to Medi-Cal Plan (MCP) Referral Form For Non Open Cases
QM076 Grievance Investigation Response Form New!
QM077 Grievance Investigation Supplemental Response Form New!
QM078 Notice of Adverse Benefit Determination (Financial Liability Dispute: NOABD-F) New!

 
 

Compliance (COM)
COM001_E Authorization for Release of Protected Health Information (PHI) Revised!
COM001_S Authorization for Release of Protected Health Information (PHI) Revised!
COM001_V Authorization for Release of Protected Health Information (PHI) (Vietnamese) Revised!
COM001-1_E Authorization for Release of PHI for Immediate Need Voucher
COM001-1_S Authorization for Release of PHI for Immediate Need Voucher (Spanish)
COM002 Sample Fax Cover Sheet
COM003 Code of Conduct and Code of Conduct Acknowledgement
COM004_E Notice of Privacy Practices and Acknowledgement of Receipt of Notice of Privacy Practices
COM004_S Notice of Privacy Practices and Acknowledgement of Receipt of Notice of Privacy Practices (Spanish)
COM005 Advance Health Care Directive Acknowledgement Form Revised!
COM006 Certification Review Hearing – Waiver of Presence
COM007 Sensitive Chart
COM008 Outpatient Treatment Authorization Request for Adults
COM009 Outpatient Treatment Authorization Request for Children/Adolescents
COM010 Outpatient Treatment Reauthorization Request for Adults
COM011 Outpatient Treatment Reauthorization Request for Children/Adolescents
COM012 Index of Confidential Info Released
COM013_E Consent for Outpatient Treatment
COM013_S Consent for Outpatient Treatment (Spanish)
COM013_V Consent for Outpatient Treatment (Vietnamese)
COM014_E Medical Care Authorization for Minor
COM014_S Medical Care Authorization for Minor (Spanish)
COM015_E Consent for Sound and/or Photographic Recordings
COM015_S Consent for Sound and/or Photographic Recordings (Spanish)
COM016_E Consent to Record and/or Photograph and Authorization for Use or Disclosure
COM016_S Consent to Record and/or Photograph and Authorization for Use or Disclosure (Spanish)
COM017 Medicare Application Worksheet
COM018_E Advance Health Care Directive Revised!
COM018_S Advance Health Care Directive (Spanish) Revised!
COM019 Delegation of TX Consent
COM020 Conflict of Interest Disclosure Statement Revised!
COM021_E Access to Medical Records Request
COM021_S Access to Medical Records Request (Spanish)
COM022_E Response to Request to Access Medical Records
COM022_S Response to Request to Access Medical Records (Spanish)
COM023_E Request to Amend Protected Health Information (PHI)
COM023_S Request Request to Amend Protected Health Information (PHI) (Spanish)
COM024_E Response to Request to Amend Protected Health Information (PHI)
COM024_S Response to Request to Amend Protected Health Information (PHI) (Spanish)
COM025 Internal Tracking of Request to Access Medical Records
COM026_E Release of Information: Patient’s Right of Access to His/Her Own Medical Record
COM026_S Release of Information: Patient’s Right of Access to His/Her Own Medical Record (Spanish)
COM027 Oath of Confidentiality Revised!
COM028_E Advance Health Care Directive (Brochure) Revised!
COM028_S Advance Health Care Directive (Brochure) (Spanish) Revised!
COM028_V Advance Health Care Directive (Brochure) (Vietnamese) Revised!
COM033 Privacy and Security Agreement Confidentiality Statement
COM034 Tracking of PHI Records Delivered Log
COM035 General Chart Room Log
COM036 Ineligible Persons Policy Acknowledgement and Attestation
COM037 Attestation Regarding Completion of Sanction Checks