Departmental Forms

Substance Use Disorder & Recovery Services (SUDRS)
ABN_Form Advance Beneficiary Notice Of Non Coverage
ADS001 Code of Professional Conduct for Drug and Alcohol Staff Acknowledgement
ADS002_E Title 22 Fair Hearing Rights
ADS002_S Title 22 Fair Hearing Rights (Spanish)
ADS003_E Notice of Personal Rights / Civil Rights
ADS003_S Notice of Personal Rights / Civil Rights
ADS006 Alcohol and Drug Services Agency Evaluation
ADS008_E Client Registration
ADS008_S Client Registration (Spanish)
ADS009 Client Episode Summary (Opening)
ADS010 Client Episode Summary (Closing)
ADS011_NTP Quality Assurance Review (NTP Specific) Revised!
ADS011_P Quality Assurance Review (Perinatal Specific) Revised!
ADS011_Y Quality Assurance (Youth Specific) Revised!
ADS012 Quality Assurance Review (Continued)
ADS020 Second Service on Same Day Progress Note
SUDRS022_E Client Admission Agreement New!
SUDRS022_S Client Admission Agreement  (Spanish) New!
SUDRS024 Medical Behavioral Health Clearance Revised!
SUDRS025 Substance Use Disorder and Recovery Services Intake Assessment New!
SUDRS026 Adult (Age 21 and Over) DMC-ODS Transition Revised!
SUDRS027 Immediate Need Profile New!
SUDRS028 Adult (Age 21 and Over) DMC-ODS Screening Revised!
SUDRS029_E Handbook Summary and Acknowledgement Form (English)
SUDRS029_S Handbook Summary and Acknowledgement Form (Spanish)
SUDRS2030_E SUDRS-MH Grievance and Appeals Process Brochure (English) New!
SUDRS2030_S SUDRS2030_S SUDRS-MH Grievance and Appeals Process Brochure (Spanish)  New!
SUDRS2030-1_E SUDRS-MH Grievance and Appeals Process Brochure-18 pt. font (English)  New!
SUDRS2030-1_S SUDRS-MH Grievance and Appeals Process Brochure-18 pt. font (Spanish)  New!
SUDRS031 Adolescent (Age 12-17) and Young Adult (Age 18-20) DMC-ODS Screening New!
SUDRS032 Adolescent (Age 12-17) DMC-ODS Screening-Parent/Caregiver Addendum New!
SUDRS033 Adolescent (Age 12-17) and Young Adult (Age 18-20) DMC-ODS Transition New!
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)
CLP009 Charge Data Invoice (JJOP)
CLP010 Charge Data Correction Invoice
CLP012 Client Resource Evaluation
CLP013 Adult Psychiatric Evaluation (Fillable)
CLP013 Adult Psychiatric Evaluation (Printable)
CLP014 Child/Adolescent Psychiatric Evaluation and Update
CLP015 Child/Adolescent Clinical Assessment
CLP015-1 Child/Adolescent Clinical Assessment-CANS-SB Revised!
CLP016_E Physical Assessment Revised!
CLP016_S Physical Assessment (Spanish) Revised!
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
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 Revised!
CLP029_S Caregiver’s Authorization Affidavit (Spanish) Revised!
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 Revised!
CLP035_E Medication Support Services Plan
CLP035_S Medication Support Services Plan (Spanish)
CLP042_E Release and Hold Harmless Agreement Revised!
CLP042_S Release and Hold Harmless Agreement (Spanish) Revised!
CLP043 HOST Care Plan
CLP044 Interdisciplinary Care Team (ICT) Referral Form
CLP045 Termination of Provider Notice Template 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!
QM024_E Your Rights Attachment (NOABD) Revised!
QM024_S Your Rights Attachment (NOABD) (Spanish) Revised!
QM025_E Your Rights Attachment (NAR) Revised!
QM025_S Your Rights Attachment (NAR) (Spanish) Revised!
QM026_E Beneficiary Nondiscrimination Notice Revised!
QM026_S Beneficiary Nondiscrimination Notice (Spanish) Revised!
QM027_E Language Assistance Taglines Revised!
QM028_E

Notice of Grievance Resolution Revised!
Letter must include these enclosures:

QM028_S

Notice of Grievance Resolution (Spanish) Revised!
Letter must include these enclosures:

QM029_E

Delivery System Notice (NOABD)  Revised!
Letter must include these enclosures:

QM029_S

Delivery System Notice (NOABD) (Spanish)  Revised!
Letter must include these enclosures:

QM030_E

Modification Notice (NOABD) Revised!
Letter must include these enclosures:

QM030_S

Modification Notice (NOABD) (Spanish) Revised!
Letter must include these enclosures:

QM031_E

Adverse Benefit Determination Upheld Revised!
Letter must include these enclosures:

QM031_S

Adverse Benefit Determination Upheld (Spanish) Revised!
Letter must include these enclosures:

QM032_E

Adverse Benefit Determination Overturned Revised!
Letter must include these enclosures:

QM032_S

Adverse Benefit Determination Overturned (Spanish) Revised!
Letter must include these enclosures:

QM033_E

Authorization Delay Notice Revised!
Letter must include these enclosures:

QM033_S

Authorization Delay Notice (Spanish) Revised!
Letter must include these enclosures:

QM034_E

Expedited Appeal Transfer Letter New!
Letter must include these enclosures:

QM034_S

Expedited Appeal Transfer Letter (Spanish) New!
Letter must include these enclosures:

QM035_E

Notice of Plan’s Request to Extend Resolution Period New!
Letter must include these enclosures:

QM035_S

Notice of Plan’s Request to Extend Resolution Period (Spanish) New!
Letter must include these enclosures:

QM036_E

Receipt of Grievance Letter New!
Letter must include these enclosures:

QM036_S

Receipt of Grievance Letter (Spanish) New!
Letter must include these enclosures:

QM037_E

Receipt of Appeal Letter New!
Letter must include these enclosures:

QM037_S

Receipt of Appeal Letter (Spanish) New!
Letter must include these enclosures:

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 Revised!
QM048_S Request for Second Opinion (Spanish) Revised!
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!
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

Denial Notice (NOABD) Revised!
Letter must include these enclosures:

QM058_S

Denial Notice (NOABD) (Spanish) Revised!
Letter must include these enclosures:

QM059_E

Termination Notice (NOABD) Revised!
Letter must include these enclosures:

QM059_S

Termination Notice (NOABD) (Spanish) Revised!
Letter must include these enclosures:

QM060_E

Payment Denial Notice (NOABD) Revised!
Letter must include these enclosures:

QM060_S

Payment Denial Notice (NOABD) (Spanish) Revised!
Letter must include these enclosures:

QM061_E

Timely Access Notice (NOABD) Revised!
Letter must include these enclosures:

QM061_S

Timely Access Notice (NOABD) (Spanish) Revised!
Letter must include these enclosures:

QM062_E

Grievance and Appeal Timely Resolution Notice (NOABD) Revised!
Letter must include these enclosures:

QM062_S

Grievance and Appeal Timely Resolution Notice (NOABD) (Spanish) Revised!
Letter must include these enclosures:

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_E

Financial Liability Notice (NOABD) Revised!
Letter must include these enclosures:

QM078_S

Financial Liability Notice (NOABD) (Spanish) Revised!
Letter must include these enclosures:

QM079 Client Services Information (CSI) Assessment Data Form New!

 
 

Compliance (COM)
COM001_E Authorization for Release of Protected Health Information (PHI) Revised!
COM001_S Authorization to Release Protected Health Information (PHI) (Spanish) Revised!
COM001_V Authorization to Release 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)
COM003 Code of Conduct and Code of Conduct Acknowledgement Revised!
COM004_E Notice of Privacy Practices and Acknowledgement of Receipt of Notice of Privacy Practices Revised!
COM004_S Notice of Privacy Practices and Acknowledgement of Receipt of Notice of Privacy Practices (Spanish) Revised!
COM006 Certification Review Hearing – Waiver of Presence Revised!
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 List of Disclosures of Protected Health Information (PHI) Revised!
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 Revised!
COM015_S Consent for Sound and/or Photographic Recordings (Spanish) Revised!
COM016_E Consent to Record and/or Photograph and Authorization for Use or Disclosure Revised!
COM016_S Consent to Record and/or Photograph and Authorization for Use or Disclosure (Spanish) Revised!
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 Revised!
COM022_S Response to Request to Access Medical Records (Spanish)
COM023_E Request to Amend Protected Health Information (PHI) Revised!
COM023_S Request Request to Amend Protected Health Information (PHI) (Spanish)
COM024_E Response to Request to Amend Protected Health Information (PHI) Revised!
COM024_S Response to Request to Amend Protected Health Information (PHI) (Spanish) Revised!
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
COM038 ACA 1557 Grievance Form Revised!