Departmental Forms

State
DHCS 1739 Mental Health Professional Licensing Waiver Request Revised!
Form W-9 Request for Taxpayer Identification Number and Certification (IRS)
MC 5829 Provider File Update (PFU) Revised!
MC 5840 Legal Entity File Update (LEFU) Revised!
MH 5120 Client Assessment
MH 5121 Client Assessment Update
MH 5122 Client Plan
MH 5123 Progress Notes Day Rehabilitation Services
MH 5124 Progress Notes Day Treatment Intensive Services
MH 5125 Service Authorization Request
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)
SUDRS003_E Notice of Personal Rights / Civil Rights Revised!
SUDRS003_S Notice of Personal Rights / Civil Rights – Spanish Revised!
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!
ADS023 Administrative Discharge Form New!
ADS024 Client Annual Update Episode Summary New!
SUDRS022_E Client Admission Agreement Revised!
SUDRS022_S Client Admission Agreement  (Spanish) Revised!
SUDRS023 Physician Consultation Referral Revised!
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 (21+) ASAM Level of Care 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) ASAM Level of Care Revised!
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!
SUDRS034 SUD Referral New!
SUDRS035_E Consent for SUD Care Coordination Services (English) New!
SUDRS035_S Consent for SUD Care Coordination Services (Spanish) New!
SUDRS036_E SUD Care Coordination Needs Determination Screening Tool (English) New!
SUDRS036_S SUD Care Coordination Needs Determination Screening Tool (Spanish) New!
SUDRS037_E SUD Care Coordination Plan (English) Revised!
SUDRS037_S SUD Care Coordination Plan (Spanish) Revised!
SUDRS038_E Care Coordination Discharge Summary (English) New!
SUDRS038_S Care Coordination Discharge Summary (Spanish) New!
SUDRS039 Recovery Services Plan New!
Children's (CHD)
CHD_INTER_E Children’s Interagency Authorization to Exchange Confidential Health Information (PHI)
Superseded by COM025_E
CHD_INTER_S Children’s Interagency Authorization to Exchange Confidential Health Information (PHI) (Spanish)
Superseded by COM025_S
CHD002 Healthy Families Mental Health Response Form
CHD012 Therapeutic Behavioral Services Service Assessment
CHD013 Therapeutic Behavioral Services Risk Assessment
CHD014 Therapeutic Behavioral Services Referral Form
CHD018 AB 2149 Intro Letter
CHD019 AB 2149 Group Home Reporting Bill Special Incident Report
CHD025_E Children’s Interagency Authorization to Exchange Confidential Health Information (PHI)
Revised!
CHD025_S Children’s Interagency Authorization to Exchange Confidential Health Information (PHI) (Spanish)
Revised!
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 Revised!
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!
CLP049 Referral for SSI Advocacy Services
CLP050 DBH 5150-5585 Form New!
Cultural Competency (CUL)
CUL002 Translation Service Request Revised!
CUL003 Outside Vendor Services Request Form
CUL004 Outside Vendor Cost Report
CUL005 Initial Contact Log
CUL006 Interpretation Service Request
CUL009 Contract Language Services Log Revised!
CUL010_E Consumer Comment Card Revised!
CUL010_S Consumer Comment Card (Spanish) New!
CUL010_V Consumer Comment Card (Vietnamese) New!
CUL011 Interpreter Feedback Form Revised!
CUL012 Request for Translation & Interpretation Services (RTIS) Form
CUL013 Quick Reference Guide of Translation and Interpretation Revised!
Medical Services (MDS)
MDS001 Quarterly Physician’s Cabinet Inspection
MDS002_E Psychotropic Medication Consent Revised!
MDS002_S Psychotropic Medication Consent(Spanish) Revised!
MDS002_V Psychotropic Medication Consent (Vietnamese) Revised!
MDS003 Verbal/Telephone Consent for Administration of Psychotropic Medication
MDS006 Alert Sheet Revised!
MDS007 Outpatient Medication Record
MDS008 Medication Visit Interdisciplinary Note
MDS009 Medication Only Case Log
MDS010 Sample Medication Log
MDS011 Patient Assistance Program Log
MDS012 Pharmaceutical Waste Log
MDS014 Monthly Medication Inspection Checklist
MDS016 Medication From Pharmacy Log
MDS017 Refrigerator Temperature Log
MDS018 Medication Room Temperature Log
MDS019 Client Pharmaceutical Log
MDS020 Return Medication to Pharmacy Log
MDS021 Requisition for Bulk or Stock Medication Revised!
MDS023 Client Oral Medication Log New!
MDS024 Clozapine Side Effect Checklist Revised!
MDS025 Adult Psychiatric Progress Note (Fillable) Revised!
MDS025 Adult Psychiatric Progress Note (Printable) Revised!
MDS026 Naloxone Distribution Project Acknowledgement Form New!
MDS027 Use of Naloxone (Narcan) Outcomes Report New!
MDS029 Child/Adolescent Psychiatric Progress Note Revised!
MH12 Mental Health Professional Licensing Waiver Request
Prevention and Early Intervention (PEI)
PEI001 Prevention and Case Management Charge Data Invoice
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!
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 Revised!
QM077 Grievance Investigation Supplemental Response Form – FILLABLE  Revised!
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!
QM082 Grievance Notification Form New!
Training (TRA)
TRA001 Training Coordination Request Form
TRA002 License Examination Preparation Program (LEPP) Application/Agreement
TRA005 License Examination Preparation Program Reimbursement Form

 
 

County
ACR7973 Notice of Acquisition Change Disposition and Completed Construction
ARMC ARMC Alerts
DBH712 Authorization for Issuance of Immediate Need Voucher(s)
RRF Children’s Fund Referral Request Form
Business Operations (BOP)
BOP001 Travel Expenditures and Claim for Payment Instructions
BOP002 Justification For Out-Of-State Travel
BOP003 Visa Justification Statement
BOP004 County Vehicle Log
BOP005 Authorization to Submit or Approve Orders
BOP006 Purchasing Procedures Flowchart
BOP007 Purchase Request
BOP008 Incentive Cards – Distribution to Participants
BOP009 Incentive Cards – Log
BOP010 Incentive Cards – Inventory
BOP011 Purchase Request Routing Slip (Petty Cash Purchases)
BOP012 Petty Cash Transaction Form
BOP013 Policy, Procedure, or Form Request
BOP014 Policy, Procedure and Form Deletion Request
BOP015 Business Card Order Form
BOP016 Stamp Order Form
BOP017 Engraving Order Form
BOP018 County Vehicle Requisition (CVR)
BOP019 Surplus Equipment
BOP020 Travel Request
BOP021 Project Request Form
BOP022 Medi-Cal Certification Packet Approval Form Revised!
BOP023 Request for Cost Center Number
BOP024 Mode of Service Revised!
BOP028 DBH Contract Provider Closure Checklist
BOP031_E Found and Saved Property-Client Notification Letter  Revised!
BOP031_S Found and Saved Property -Client Notification Letter (Spanish) Revised!
BOP032 Provider Attestation – 90 Day Rule
BOP033 Provider Attestation – 120 Day Rule
BOP034 Found and Saved Property Log Revised!
BOP039_E Financial Interviewer Letter (English) Revised!
BOP039_S Financial Interviewer Letter (Spanish) Revised!
Clerical (CLK)
CLK003 Scheduling Template
CLK004 Schedule Change Request
CLK006 Physician Request Form
CLK028 myAvatar Program Assignment (Mental Health) New!
CLK028_S myAvatar Program Assignment (Mental Health)(Spanish) New!
CLK029 myAvatar CSI Assessment New!
CLK029_S myAvatar CSI Assessment (Spanish) New!
CLK030 myAvatar Initial Contact Form (Mental Health) New!
CLK030_S myAvatar Initial Contact Form (Mental Health) (Spanish) 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
COM010 Outpatient Treatment Reauthorization Request for Adults
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!
COM038_S ACA 1557 Grievance Form (Spanish) New!
COM039 E-Signature and Provider Signature List
COM040_E  DBH & BBS Complaint Notifications to Clients (8-20) New!
COM040_S DBH & BBS Complaint Notifications to Clients (8-20) (Spanish) New!
Human Resources (HR)
HR001 Position/Justification Form
HR002 Waiver Request Cover Letter
HR003 Pre-Licensed MFT/MSW/PCC Statement of Awareness of Need to Obtain Licensure for Employment
HR004 Overtime Authorization
HR005 Unpaid Leave Due to No Proof of License or Registration
HR006 Pre-Licensed/Out-of-State Licensed Ready Psychologists Statement of Awareness of Need to Obtain Licensure for Employment
HR007 Standards of Dress and Grooming Acknowledgement Form
HR008 Department of Behavioral Health Intra-Department Transfer (IDT) Form
HR009 Borrowed Position Requisition
HR010 Property Return Checklist for Separating Employees
HR011 Exit Interview Form Revised!
HR012 Employee Information Checklist
HR013 DBH New Hire Welcome Letter
HR014 Tuberculosis Screening Confirmation
HR015 Volunteer Services Program Request Form
HR016 4/10 Work Schedule Agreement
HR017 9/80 Work Schedule Agreement
HR018 Deviation to Traditional Work Schedule Agreement
HR019 Employee Intra-Department Reassignment Request
Nursing (NUR)
NUR001 Nursing Staff Unit-Specific Orientation Competencies Checklist
NUR002 Nursing Staff Relias Orientation Training Revised!
Patients' Rights (PR)
PR001_E Patients’ Rights Grievance Form Revised!
PR001_S Patients’ Rights Grievance Form (Spanish) Revised!
PR002_E Patients’ Rights Office Grievance Appeal Form Revised!
PR002_S Patients’ Rights Office Grievance Appeal Form (Spanish) Revised!
Safety (SFT)
SFT005 Kiln Safeguards
SFT006 Kiln Quarterly Safety Checklist
SFT039 Safety Concern Report
SFT047 Investigation of Workplace Incidents, Occupational Injury, Illnesses and Hazardous Exposure
SFT050 Bomb Threat Checklist
SFT051 Location Safety Coordinator (LSC)(sign) Revised!
SFT052 HIPAA Baseline Privacy & Security Walkthrough Audit
SFT053 DBH Safety Program (Emergency Agency Action Plan (EAP))
SFT054 DBH Med Waste Mgm (MWM) Program (Responsible Staff & Clinics with MWN Programs)
SFT055 DBH Haz Com Program (Laws & Regulations)
SFT056 DBH Safety Program (Fire Drill Reports)