Documents

Departmental FormsDepartmental Forms
Standard Practice ManualStandard Practice Manual
Information NoticesInformation Notices
Interim Instruction NoticesInterim Instruction Notices
ResourcesResources

Name	Modified Date	Program and Number
Change of Provider Request Form – 18pt. font (Spanish)	06/28/2022	QM047_S
Translation Service Request Form	08/16/2022	CUL002
Interpretation Service Request Form	08/16/2022	CUL006
Opioid Agreement for Buprenorphine Medication Assisted Treatment (Spanish)	08/02/2022	SUDRS040_S
Opioid Agreement for Buprenorphine Medication Assisted Treatment (English)	08/02/2022	SUDRS040_E
Electronic Signature Request Checklist	08/03/2022	COM043
Out of Network Services Request	07/12/2022	QM039
Beneficiary Nondiscrimination Notice (Mandarin)”	07/28/2022	QM026_M
Beneficiary Nondiscrimination Notice (Vietnamese)	07/28/2022	QM026_V
Your Rights Attachment (NOABD) (Mandarin)	07/28/2022	QM024_M
Your Rights Attachment (NOABD) (Vietnamese)	07/28/2022	QM024_V
Change of Provider Request Form – 18pt. font (English)	06/28/2022	QM047_E
Code of Professional Conduct for Drug and Alcohol Staff	05/05/2022	SUDRS001
Adolescent (Age 12-17) and Young Adult ASAM TRIAGE LEVEL OF CARE SCREENING – Instructions	05/09/2022	SUDRS044
Consent for SUD Care Coordination Services (Spanish)		SUDRS035_S
Care Coordination Needs Determination Screening Tool (English)		SUDRS036_E
SUD Care Coordination Needs Determination Screening Tool (Spanish)		SUDRS036_S
SUD Care Coordination Plan (English)		SUDRS037_E
SUD Care Coordination Plan (Spanish)		SUDRS037_S SUD
Care Coordination Discharge Summary (English)		SUDRS038_E
Care Coordination Discharge Summary (Spanish)		SUDRS038_S
CalOMS Administrative Discharge		SUDRS045
CalOMS Admission		SUDRS046
CalOMS Admission Instructions		SUDRS047
CalOMS Standard Discharge		SUDRS048
CalOMS Standard Discharge Instructions		SUDRS049
Privacy and Security Incident Reporting Form	05/03/2022	COM042
Medi Cal Fee For Service Provider Manual		MHPFFS51319
Taxonomy Codes	09/16/2021
Staff Master Worksheet Update
Staff Master Worksheet
Mental Health Professional Licensing Waiver Request	05/10/2021	DHCS 1739
Title 22 Fair Hearing Rights	09/23/2021	ADS002_E
Title 22 Fair Hearing Rights (Spanish)	05/10/2021	ADS002_S
Notice of Personal Rights / Civil Rights	08/03/2022	SUDRS003_E
Notice of Personal Rights / Civil Rights – Spanish	08/03/2022	SUDRS003_S
Client Admission Agreement	05/10/2021	SUDRS022_E
Client Admission Agreement (Spanish)	05/10/2021	SUDRS022_S
Substance Use Disorder and Recovery Services Intake Ass	05/10/2021	SUDRS025
Adult (Age 21 and Over) DMC-ODS Transition		SUDRS026
Immediate Need Profile	05/06/2022	SUDRS027
Adult (21+) ASAM Level of Care Screening	05/18/2022	SUDRS028
Handbook Summary and Acknowledgement Form (English)	05/10/2021	SUDRS029_E
Handbook Summary and Acknowledgement Form (Spanish)	05/10/2021	SUDRS029_S
SUDRS-MH Grievance and Appeals Process Brochure (English)	05/10/2021	SUDRS030_E
SUDRS-MH Grievance and Appeals Process Brochure (Spanish)	05/10/2021	SUDRS030_S
SUDRS-MH Grievance and Appeals Process Brochure- 18pt. font (Spanish)	05/10/2021	SUDRS030_S
SUDRS-MH Grievance and Appeals Process Brochure-18pt. font (English)		SUDRS030_E
Adolescent (Age 12-17) and Young Adult ASAM Level of Care Screening	05/18/2022	SUDRS031
Adolescent (Age 12-17) and Young Adult (Age 18-20) DMC-ODS Transition New!	05/10/2021	SUDRS033
SUD Referral	07/20/2022	SUDRS034
Recovery Services Plan	05/10/2021	SUDRS039
Level of Care (LOC)	05/10/2021	SUDRS042
CalOMS Youth-Detox Discharge	05/10/2021	SUDRS050
CalOMS Admission (Outpatient)	05/10/2021	SUDRS051
CalOMS Annual Update	05/10/2021	SUDRS052
Children’s Interagency Authorization to Exchange Confidential Health Information (PHI) Superseded by COM025_E	05/11/2021	CHD_INTER_E
Children’s Interagency Authorization to Exchange Confidential Health Information (PHI) (Spanish) Superseded by COM025_S	05/11/2021	CHD_INTER_S
Therapeutic Behavioral Services Service Assessment	05/11/2021	CHD012
Therapeutic Behavioral Services Risk Assessment	05/11/2021	CHD013
Therapeutic Behavioral Services Referral Form	05/11/2021	CHD014
Children’s Interagency Authorization to Exchange Confidential Health Information (PHI)	05/11/2021	CHD025_E
Children’s Interagency Authorization to Exchange Confidential Health Information (PHI) (Spanish)	05/11/2021	CHD025_S
Episode Opening and Closing Codes	05/11/2021	CLP_CODES
Client Payment Agreement	05/11/2021	CLP001
Client Episode Summary (CSI)	05/11/2021	CLP002
Initial Contact Form (English)	08/26/2021	CLP003_E
Initial Contact Form (Spanish)	05/11/2021	CLP003_S
CSI Periodic Data	05/11/2021	CLP004
Adult Clinical Assessment (A-1)	05/11/2021	CLP005
Universal Charge Data Invoice	06/13/2022	CLP006
Charge Data Invoice	02/15/2022	CLP009
Client Resource Evaluation	02/15/2022	CLP012
Adult Psychiatric Evaluation (Fillable)	02/15/2022	CLP013 (Fill)
Adult Psychiatric Evaluation (Fillable)	02/15/2022	CLP013 (Print)
Child/Adolescent Psychiatric Evaluation and Update	05/11/2021	CLP014
Child/Adolescent Clinical Assessment	05/11/2021	CLP015
Child/Adolescent Clinical Assessment-CANS-SB	05/11/2021	CLP015-1
Physical Assessment	05/11/2021	CLP016_E
Physical Assessment (Spanish)	05/11/2021	CLP016_S
Client Recovery Evaluation (Annual)	05/11/2021	CLP017
Request to Waive Consumer’s Responsibility to Pay for Medications	05/11/2021	CLP018
Care Necessity	05/11/2021	CLP019
Psychological Testing Referral Form	04/13/2022	CLP020
Healthy Homes Screening/Assessment	05/11/2021	CLP021
Diagnosis	05/11/2021	CLP022
Client Recovery Plan/ISSP	05/11/2021	CLP024_E
Client Recovery Plan/ISSP (Spanish)	05/11/2021	CLP024_S
Discharge Summary	05/11/2021	CLP025
Abnormal Involuntary Movement Scale	05/11/2021	CLP026
Interdisciplinary Note	02/15/2022	CLP027
Services Teams Actions	02/16/2022	CLP028
Caregiver’s Authorization Affidavit	05/11/2021	CLP029_E
Caregiver’s Authorization Affidavit (Spanish)	05/11/2021	CLP029_S
Request for Verification of Veterans Status for Mental Health and/or Substance Abuse Services	05/11/2021	CLP030
Consent and Authorization to Exchange Confidential Information for Veterans Status	05/11/2021	CLP031
Medication Support Services Plan	05/11/2021	CLP035_E
Medication Support Services Plan (Spanish)	05/11/2021	CLP035_S
Release and Hold Harmless Agreement	05/11/2021	CLP042_E
Release and Hold Harmless Agreement (Spanish)	05/11/2021	CLP042_S
HOST Care Plan	05/11/2021	CLP043
Interdisciplinary Care Team (ICT) Referral Form	05/11/2021	CLP044
DBH 5150-5585 Form	03/02/2022	CLP050
Columbia-Suicide Severity Rating Scale	05/11/2021	CLP051
Chart Audit Tool	05/11/2021	QM001
Annual Psychiatric Assessment Review Form	05/11/2021	QM005
Interdisciplinary Care Team (ICT) Referral Form	05/11/2021	QM018
Guidelines for Completing Referral Summary for Referral to Managed Care Plan (MCP) Attachment	05/11/2021	QM018_1
Tier Transition Letter Attachment II	05/11/2021	QM020_E
Tier Transition Letter Attachment II (Spanish)	05/11/2021	QM020_S
Your Rights Attachment (NOABD)	05/11/2021	QM024_E
Your Rights Attachment (NOABD) (Spanish)	05/11/2021	QM024_S
Your Rights Attachment (NAR)	05/11/2021	QM025_E
Your Rights Attachment (NAR) (Spanish)	05/11/2021	QM025_S
Beneficiary Nondiscrimination Notice	05/11/2021	QM026_E
Beneficiary Nondiscrimination Notice (Spanish)	05/11/2021	QM026_S
Language Assistance Taglines	05/11/2021	QM027_E
Delivery System Notice (NOABD) (Vietnamese)”	07/27/2022	QM029_V
Delivery System Notice (NOABD)	07/28/2022	QM029_E
Delivery System Notice (NOABD) (Spanish)	07/28/2022	QM029_S
Delivery System Notice (NOABD) (Mandarin)	07/27/2022	QM029_M
Modification Notice (NOABD)	07/28/2022	QM030_E
Modification Notice (NOABD) (Mandarin)	07/27/2022	QM030_M
Modification Notice (NOABD) (Vietnamese)	07/27/2022	QM030_V
QM030_S “Modification Notice (NOABD) (Spanish)	07/28/2022	QM030_S
Change Order Request Routing Slip	05/11/2021	QM044
State Pre-Audit Chart Review Audit Tool	05/11/2021	QM046
Change of Provider Request Form	06/28/2022	QM047_E
Change of Provider Request Form (Spanish)	06/28/2022	QM047_S
Request for Second Opinion QM048_E Revised!	08/24/2021	QM048_E
Request for Second Opinion (Spanish) QM048_S Revised!	08/24/2021	QM048_S
Mental Health and Alcohol and Drug Services Agency Evaluation	05/11/2021	QM049
Grievance Form	05/11/2021	QM050_E
Grievance Form (Spanish)	05/11/2021	QM050_S
Action Appeal Form	05/11/2021	QM051_E
Quality Assurance Audit At Annual Point	05/11/2021	QM056
Medication Monitoring Questionnaire	05/11/2021	QM057
Denial Notice (NOABD) (Vietnamese)	07/27/2022	QM058_V
Denial Notice (NOABD) (Mandarin)	07/27/2022	QM058_M
Denial Notice (NOABD)	07/28/2022	QM058_E
Denial Notice (NOABD) (Spanish)	07/28/2022	QM058_S
Termination Notice (NOABD)	05/11/2021	QM059_E
Termination Notice (NOABD) (Spanish)	05/11/2021	QM059_S
Timely Access Notice (NOABD)	07/28/2022	QM061_E
Timely Access Notice (NOABD) (Spanish)	07/28/2022	QM061_S
Timely Access Notice (NOABD) (Mandarin)	07/27/2022	QM061_M
Timely Access Notice (NOABD) (Vietnamese)	07/27/2022	QM061_V
Medi-Cal Site Certification Checklist	07/19/2022	QM074
Mental Health Plan (MHP) to Medi-Cal Plan (MCP) Referral Form For Non Open Cases	05/11/2021	QM075
Financial Liability Notice (NOABD)	07/28/2022	QM078_E
Financial Liability Notice (NOABD) (Spanish)	07/28/2022	QM078_S
Financial Liability Notice (NOABD) (Mandarin)	07/27/2022	QM078_M
Financial Liability Notice (NOABD) (Vietnamese)	07/27/2022	QM078_V
Scheduling Template	05/11/2021	CLK003
Schedule Change Request	05/11/2021	CLK004
Physician Request Form	05/11/2021	CLK006
myAvatar Program Assignment (Mental Health)	05/11/2021	CLK028
myAvatar Program Assignment (Mental Health)(Spanish)	05/11/2021	CLK028_S
myAvatar CSI Assessment	05/11/2021	CLK029
myAvatar CSI Assessment (Spanish)	05/11/2021	CLK029_S
myAvatar Initial Contact Form (Mental Health	05/11/2021	CLK030
myAvatar Initial Contact Form (Mental Health) (Spanish)	05/11/2021	CLK030_S
Authorization to Release Protected Health Information (PHI)	08/09/2021	COM001_E
Authorization to Release Protected Health Information (PHI) (Spanish)	08/23/2021	COM001_S
Authorization to Release Protected Health Information (PHI) (Vietnamese)	09/15/2021	COM001_V
Code of Conduct and Code of Conduct Acknowledgement	05/11/2021	COM003
Notice of Privacy Practices and Acknowledgement of Receipt of Notice of Privacy Practices	05/11/2021	COM004_E
Notice of Privacy Practices and Acknowledgement of Receipt of Notice of Privacy Practices (Spanish)	05/11/2021	COM004_S
Certification Review Hearing – Waiver of Presence	05/11/2021	COM006
Sensitive Chart	05/11/2021	COM007
Outpatient Treatment Reauthorization Request for Adults	05/11/2021	COM010
List of Disclosures of Protected Health Information (PHI)	05/11/2021	COM012
Consent for Outpatient Treatment	05/11/2021	COM013_E
Consent for Outpatient Treatment (Spanish)	05/11/2021	COM013_S
Consent for Outpatient Treatment (Vietnamese)	05/11/2021	COM013_V
Medical Care Authorization for Minor	05/11/2021	COM014_E
Medical Care Authorization for Minor (Spanish)	05/11/2021	COM014_S
Consent for Sound and/or Photographic Recordings	05/11/2021	COM015_E
Consent for Sound and/or Photographic Recordings (Spanish)	05/11/2021	COM015_S
Consent to Record and/or Photograph and Authorization for Use or Disclosure	05/11/2021	COM016_E
Consent to Record and/or Photograph and Authorization for Use or Disclosure (Spanish)	05/11/2021	COM016_S
Advance Health Care Directive	05/11/2021	COM018_E
Advance Health Care Directive (Spanish)	05/11/2021	COM018_S
Delegation of TX Consent	05/11/2021	COM019
Conflict of Interest Disclosure Statement	07/27/2022	COM020
Access to Medical Records Request	05/11/2021	COM021_E
Access to Medical Records Request (Spanish)	05/11/2021	COM021_S
Response to Request to Access Medical Records	05/11/2021	COM022_E
Response to Request to Access Medical Records (Spanish)	05/11/2021	COM022_S
Request to Amend Protected Health Information (PHI)	05/11/2021	COM023_E
Request Request to Amend Protected Health Information (PHI) (Spanish)	05/11/2021	COM023_S
Response to Request to Amend Protected Health Information (PHI)	05/11/2021	COM024_E
Response to Request to Amend Protected Health Information (PHI) (Spanish)	05/11/2021	COM024_S
Internal Tracking of Request to Access Medical Records	05/11/2021	COM025
Release of Information: Patient’s Right of Access to His/Her Own Medical Record	05/11/2021	COM026_E
Release of Information: Patient’s Right of Access to His/Her Own Medical Record (Spanish)	05/11/2021	COM026_S
Oath of Confidentiality	01/14/2022	COM027
Advance Health Care Directive (Brochure)	05/11/2021	COM028_E
Advance Health Care Directive (Brochure) (Spanish)	05/11/2021	COM028_S
Advance Health Care Directive (Brochure) (Vietnamese)	05/11/2021	COM028_V
Privacy and Security Agreement Confidentiality Statement	05/11/2021	COM033
Tracking of PHI Records Delivered Log	05/11/2021	COM034
General Chart Room Log	05/11/2021	COM035
Ineligible Persons Policy Acknowledgement and Attestation	05/11/2021	COM036
Attestation Regarding Completion of Sanction Checks	05/11/2021	COM037
ACA 1557 Grievance Form	05/11/2021	COM038
ACA 1557 Grievance Form (Spanish)	05/11/2021	COM038_S
Electronic Signature Agreement and E-Signature and Provider Signature List	08/03/2022	COM039
DBH & BBS Complaint Notifications to Clients (8-20)	05/11/2021	COM040_E
DBH & BBS Complaint Notifications to Clients (8-20) (Spanish)	05/11/2021	COM040_S
myAvatar Policy/Procedure Acknowledgement Form	05/11/2021	COM041
Patients’ Rights Grievance Form	05/11/2021	PR001_E
Patients’ Rights Grievance Form (Spanish)	05/11/2021	PR001_S
Patients’ Rights Office Grievance Appeal Form	05/11/2021	PR002_E
Patients’ Rights Office Grievance Appeal Form (Spanish)	05/11/2021	PR002_S
Service Authorization Request 03/01/2009	08/12/2021	MH5125
Client Assessment 03/01/2009	08/12/2021	MH5120
Client Assessment Update 03/01/2009	08/12/2021	MH5121
Client Plan 03/01/2009	08/12/2021	MH5122
Action Appeal Form (Spanish)	09/01/2021	QM051_S
Request for Restriction of Confidential Communication	09/16/2021	COM030_E
Request for Restriction of Confidential Communication (Spanish)	09/16/2021	COM030_S
Response to Request for Restriction of Confidential Information	09/16/2021	COM031_E
Response to Request for Restriction of Confidential Information (Spanish)	09/16/2021	COM031_S
Notice to Consumer English MD	10/21/2021	MDS030
Notice to Consumer Spanish MD	10/21/2021	MDS030_S
Notice to Consumer English DO	10/21/2021	MDS031
Notice to Consumer Spanish DO	06/15/2022	MDS031_S
Medical/Behavioral Health Clearance	11/22/2021	SUDRS024
Payment Denial Notice	11/22/2021	QM060_E
Payment Denial Notice (Spanish)	11/22/2021	QM060_S
Authorization Delay Notice	11/22/2021	QM033_E
Authorization Delay Notice (Spanish)	11/22/2021	QM033_S
Grievance and Appeal Timely Resolution Notice	11/22/2021	QM062_E
Grievance and Appeal Timely Resolution Notice (Spanish)	11/22/2021	QM062_S
Unusual Occurrence/Incident Report	04/07/2022	QM053
Termination of Provider Notice Template	05/11/2022	CLP045
Mode of Service	04/28/2022	BOP024
Adult (21+) ASAM Triage Level of Care Screening	05/05/2022	SUDRS043
Consent for SUD Care Coordination Services (English)		SUDRS035_E
Termination of Provider Notice Template_Spanish	05/25/2022	CLP045_S
Notice of Grievance Resolution	06/23/2022	QM028_E
Notice of Grievance Resolution (Spanish)	06/23/2022	QM028_S
Receipt of Grievance Acknowledgement Letter	06/23/2022	QM036_E
Receipt of Grievance Acknowledgement Letter (Spanish)	06/23/2022	QM036_S
Grievance Investigation Response Form	06/23/2022	QM076_E
Grievance Investigation Supplemental Response Form	06/23/2022	QM077_E
Fagerstrom Test for Nicotine Dependence	06/22/2022	SUDRS053

Name	Modified Date	Program and Number
Continuity of Care Procedure	07/18/2022	QM6044-2
Network Adequacy Policy	05/17/2021	QM6043
DMC-ODS Requirements for period 2022-2026	08/08/2022	SUDRS0241
Documentation Requirements for all SMHS DMC and DMC-ODS Services	07/28/2022	QM6056
Transition of Care Procedure	07/18/2022	QM6044-3
Clinical Supervision for Pre-Licensed Psychologists	02/16/2022	CLP0842
DBH-IT Data Encryption	02/28/2022	IT5018
DATAR Policy (SUDRS0236)	07/22/2022	SUDRS0236
DATAR Procedure (SUDRS0236-1)	12/15/2021	SUDRS0236-1
Request to Change the DBH Websites Policy (BOP3047)	12/15/2021	BOP3047
Request to Change the DBH Websites Procedure (BOP3047-1)	12/15/2021	BOP3047-1
Physician Consultation Services	09/13/2021	SUDRS0224
Control, Access, Accountability-Meds Supplies Policy	09/13/2021	MDS2008
Scope of Practice Billing Guide
Outpatient Chart Manual
Adult System of Care, Intensive and Aggressive Case Management, and ACSP Coordinated Services	05/13/2021	ADT0101
Case Management Services	05/13/2021	ADT0102
Reporting Dependent Adult/Elder Abuse and Neglect Policy	05/13/2021	ADT0103
Reporting Dependent Adult/Elder Abuse Procedure	05/13/2021	ADT0103-01
Adult System of Care Out-of-County Placement Policy	05/13/2021	ADT0105
Forensic Contraband Policy and Procedure	05/13/2021	ADT0106
DBH Alcohol and Other Drug (AOD) Programs Counselor Certification Policy	05/13/2021	ADS0201
Alcohol and Drug Services Code of Professional Conduct Policy	05/13/2021	ADS0202
Title 22 Fair Hearing Rights Policy	05/13/2021	ADS0205
Charitable Choice Procedure	10/06/2021	SUDRS0209-1
Medication Policy for Clients Seeking Alcohol and Drug Treatment Services	05/13/2021	ADS0210
Alcohol and Drug Services (ADS) Youth Treatment Policy	05/13/2021	ADS0212
Alcohol and Drug Services (ADS) Perinatal Treatment Policy	05/13/2021	ADS0213
Admission Preference and Interim Services Policy	09/13/2021	SUDRS0214
Admission Preference and Interim Services Procedure		SUDRS0214-1
Accessibility of Services Policy	08/15/2022	SUDRS0220
Expenditure of the Substance Abuse Prevention and Treatment Block Grant Policy	05/13/2021	ADS0221
Substance Use Disorder Medication Safety and Effectiveness Policy	05/13/2021	SUDRS0223
Substance Use Disorder Service Utilization Policy	05/13/2021	SUDRS0225
Substance Use Disorder and Recovery Services Coordination of Care Policy	05/13/2021	SUDRS0228
Substance Use Disorder and Recovery Services Coordination of Care Procedure	05/13/2021	SUDRS0228-1
California Outcomes Measurement System	05/13/2021	SUDRS0229
California Outcomes Measurement System	04/13/2022	SUDRS0229-1
Post Client Satisfaction Survey Procedure	05/13/2021	SUDRS0230
Substance Use Disorder and Recovery Services Residential Prior Authorization Policy	05/13/2021	SUDRS0231
Case Management Services for Child and Adolescent Clients	05/13/2021	CHD0302
Child Abuse Reporting Policy	05/13/2021	CHD0303
Child Abuse Reporting Procedure	05/13/2021	CHD0303-1
AB 2726 Program Policy	05/13/2021	CHD0307
Financial Interviewer Procedure	05/13/2021	CHD0308
Healthy Families SED Services Policy	05/13/2021	CHD0309
Healthy Families SED Services Procedure	05/13/2021	CHD0309-1
Providing Services to Foster Care, Adoption Assistance Program (AAP) and Kinship Guardianship Assistance Payment (KinGAP) Children Placed Out-of County Policy	05/13/2021	CHD0311
Providing Services to Foster Care Children Placed Out-of-County Procedure	05/13/2021	CHD0311-1
Providing Services to Adoption Assistance Program (AAP) and Kinship Guardianship Assistance Payment (KinGAP) Children Placed Out-of County Procedure	05/13/2021	CHD0311-2
Children’s Fund Immediate Need Voucher Policy	05/13/2021	CHD0315
Children’s Fund Immediate Need Voucher Procedure	05/13/2021	CHD0315-1
Consent for Treatment of Minors Policy	05/13/2021	CHD0316
Consent to Treat a Minor: Procedures for Parents/Legal Guardians	05/13/2021	CHD0316-1
Consent to Treat a Dependent Minor Procedure	05/13/2021	CHD0316-2
Reporting Dependent Adult/Elder Abuse and Neglect Policy	05/13/2021	ADT0103
Reporting Dependent Adult/Elder Abuse Procedure	05/13/2021	ADT0103-1
Outpatient Chart Manual (OCM)	05/13/2021	OCM
Lost and Found Procedure	05/13/2021	CLK0701
Assignment of Meeting Rooms	05/13/2021	CLK0702
Clinic Responsibility for Processing Client Registration, PFI, CDI	05/13/2021	CLK0703
Charge Data Invoice (CDI) Process Procedure	05/13/2021	CLK0704
Scheduling Application Policy	05/13/2021	CLK0705
Correction of Overlapping Service	05/13/2021	CLK0707
Service Deletions and Corrections	05/13/2021	CLK0708
Initial Contact Form	05/13/2021	CLK0711
Procedure for Unscheduled Appointments	05/13/2021	CLK0712
Appointment Scheduling	05/13/2021	CLK0713
No Show Policy	05/13/2021	CLK0714
Field Trips/Conferences	05/13/2021	CLP0802
Treatment of DBH Employees by DBH Facilities	05/13/2021	CLP0804
Acknowledgement of Abuse Reporting Duties Policy	05/13/2021	CLP0805
Clinical Supervision for Licensure AMFT, ACSW, APCC	02/16/2022	CLP0806
Supervision of Occupational Therapists	05/13/2021	CLP0807
Consumer Benefit Assistance Protocol	05/13/2021	CLP0808
Admission Standards for Penal Code Misdemeanor Violations	05/13/2021	CLP0809
Diagnosis of Mental Disorder	05/13/2021	CLP0810
Out-of-County Access for Mental Health Services	05/13/2021	CLP0812
Self Help Group Protocol	05/13/2021	CLP0814
Adjustment of Client Fees	05/13/2021	CLP0815
Waiver of Consumer’s Responsibility to Pay for Medications	05/13/2021	CLP0816
Policies Regarding Authorization and Designation Pursuant to the Lanterman-Petris-Short (LPS) Act	05/13/2021	CLP0818
Duty to Warn and Protect Third Parties in	05/13/2021	CLP0819
Duty to Warn and Protect Third Parties in Response to a Client Threat (Tarasoff) Procedure	05/13/2021	CLP0819-1
Day Treatment Weekly Charting in Staff Meetings	05/13/2021	CLP0821
Psychological Testing	05/13/2021	CLP0822
HIV and AIDS Charting	05/13/2021	CLP0824
Confidentiality When Dealing with Client Support Persons	05/13/2021	CLP0825
Disability Application	05/13/2021	CLP0826
Veterans Services Policy	05/13/2021	CLP0828
Veterans Services Procedure	05/13/2021	CLP0828-1
5150/5585 Transportation Policy	05/13/2021	CLP0829
5150/5585 Transportation Procedure	05/13/2021	CLP0829-1
Clients with Physical Medical Conditions Policy	05/13/2021	CLP0830
CWIC Referral Procedure	05/13/2021	CLP0831
Bus Pass Program Policy	05/13/2021	CLP0832
Shelter Bed Services Policy	05/13/2021	CLP0833
Client Substance Use Policy	05/13/2021	CLP0834
Client Substance Use Screening Procedure	05/13/2021	CLP0834-1
Transformational Collaborative Outcomes Management (TCOM) Policy	05/13/2021	CLP0836
Transformational Collaborative Outcomes Management (TCOM) Procedure	05/13/2021	CLP0836-1
Client Notice Regarding Termination of Provider Procedure	04/12/2022	CLP0837
Sending Confidential Information by Facsimile	05/13/2021	COM0901
Subpoena of Medical Records	05/13/2021	COM0902
Advance Health Care Directive Policy	05/13/2021	COM0903
Medical Records Security Policy for Outpatient Services	05/13/2021	COM904
Confidentiality of Protected Health Information (PHI)	05/13/2021	COM0905
Retention of Medical Records Policy	05/13/2021	COM0906
Unauthorized Access of Confidential Medical Records	05/13/2021	COM0907
Medical Records Requiring Special Handling	05/13/2021	COM0908
Medical Records Requiring Special Handling Procedure	05/13/2021	COM0908-1
Electronic Transfer of Client PHI	05/13/2021	COM0909
HIPAA Notice of Privacy Practices (NOPP) Policy	05/13/2021	COM0910
Conflict of Interest Policy	07/27/2022	COM0911
Authorization to Release PHI Policy	08/09/2021	COM0912
Authorization to Release Protected Health Information (PHI) Procedure	01/14/2022	COM0912-1
Trafficking Victims Protection Act of 2000	05/13/2021	COM0913
Code of Conduct	05/13/2021	COM0914
Certification of Billed Services	05/13/2021	COM0915
Compliance Verification, Monitoring and Auditing Policy	05/13/2021	COM0917
Compliance Hotline Policy	05/13/2021	COM0919
Compliance Hotline Procedure	05/13/2021	COM0919-1
DBH Compliance Committee	05/13/2021	COM0920
Sound and Photographic Recordings Policy	05/13/2021	COM0922
Security of Protected Electronic Health Information Policy	05/13/2021	COM0923
Workstation and System Security Policy	05/13/2021	COM0924
Data Integrity Policy	05/13/2021	COM0925
Privacy and Security Incident Sanctions	01/19/2022	COM0926
Fraud, Waste and Abuse Prevention Policy	05/13/2021	COM0927
Access and Amendment of Medical Records Policy	05/13/2021	COM0931
Ineligible Persons Procedure	08/11/2022	COM0933-1
Ineligible Persons Policy	08/11/2022	COM0933
Compliance Plan Policy	05/13/2021	COM0934
Patients’ Rights Policy	05/13/2021	COM0935
Patients’ Rights Inpatient Grievance Process	05/13/2021	COM0935-1
Patients’ Rights Outpatient Grievance Process	05/13/2021	COM0935-2
HIPAA National Provider Identifier (NPI) Policy	05/13/2021	COM0938
HIPAA National Provider Identifier (NPI) Procedure	05/13/2021	COM0938-1
Root Cause Analysis Policy	05/13/2021	COM0939
Right to Request Alternative Means of Communication Protected Health Information Policy	05/13/2021	COM0941
Medicare Provider Certification Policy	05/13/2021	COM0942
Medi-Cal Eligibility Data Systems (MEDS) Policy	05/13/2021	COM0943
MEDS Access and Contacts Procedure	05/13/2021	COM0943-1
Privacy or Security Incident Policy	05/13/2021	COM0944
Client Grievance Policy	05/13/2021	COM0946
MHSA Issue Resolution Process	05/13/2021	COM0947
Transportation of Protected Health Information (PHI) Policy	05/13/2021	COM0948
Transportation of Protected Health Information (PHI) Procedure	05/13/2021	COM0948-1
Non-Discrimination – Section 1557 of the Affordable Care Act Policy	05/13/2021	COM0953
Affordable Care Act (ACA) 1557 Grievance Procedure	05/13/2021	COM953-1
Overpayment Policy	05/13/2021	COM0954
Behavioral Health Services for Clients/Family	05/17/2021	CUL1002
Behavioral Health Services for Clients/Family	05/17/2021	CUL1002-1
Satisfying Clients’ Language Needs	05/17/2021	CUL1004
Consumer Focus Group Policy	05/17/2021	CUL1005
Consumer Focus Group Procedure	05/17/2021	CUL1005-1
Cultural Competency Policy	05/17/2021	CUL1006
Field Testing of Written Materials Policy	05/17/2021	CUL1010
Field Testing of Written Materials Procedure	05/17/2021	CUL1010-1
Providing Translation Services Procedure	05/17/2021	CUL1011
Providing Interpretation Services Procedure	06/13/2022	CUL1012
Providing Written Communications in Threshold/Primary Languages for Consumers/Family Members Policy	05/17/2021	CUL1013
Cultural Competency Training Policy	05/17/2021	CUL1014
Medical Services Staff Organization	05/17/2021	MDS2002
Incorporated Employees – Fiscal Control Procedures	05/17/2021	MDS2003
Guidelines For Psychiatrists Assigned to Outpatient Clinics	05/17/2021	MDS2004
Leave of Absence – Physicians	05/17/2021	MDS2005
Deviation from Standard of Practice of Medicine	05/17/2021	MDS2006
Benzodiazepine Medication Policy	05/17/2021	MDS2007
Control, Access and Accountability of Medications and Medical Supplies Policy	05/17/2021
Control, Access and Accountability of Medications and Medical Supplies Procedure	05/17/2021	MDS2008-1
Controlled Substance Utilization Review and Evaluation System (CURES) Policy	05/17/2021	MDS2010
Controlled Substance Utilization Review and Evaluation System (CURES) Procedure	05/17/2021	MDS2010-1
Medication Appointment – Scheduling	05/17/2021	MDS2011
Sample Injectable Medication Policy	05/17/2021	MDS2012
Handling of Contaminated Waste/Needles and Syringes	05/17/2021	MDS2014
Prescription Policy	05/17/2021	MDS2015
Disability Application	05/17/2021	MDS2016
Consent for Administration of Psychotropic Medication to Minors Policy	05/17/2021	MDS2017
Physician’s Orders (Treatment Plan)	05/17/2021	MDS2018
Laboratory Services/Physical Assessment Policy	05/17/2021	MDS2019
Laboratory Services/Physical Assessment Procedure	05/17/2021	MDS2019-1
Medication Support Groups	05/17/2021	MDS2020
Medical Services Credentialing Procedure	05/17/2021	MDS2021
Patient Assistance Program Policy	05/17/2021	MDS2022
Patient Assistance Program Procedure	05/17/2021	MDS2022-1
Clinical Practice Guideline: Clozapine	05/17/2021	MDS2025
Telehealth Policy	05/17/2021	MDS2027
Telehealth Procedure	05/17/2021	MDS2027-1
Intranasal Naloxone Policy	05/17/2021	MDS2028
Intranasal Naloxone Procedure	05/17/2021	MDS2028-1
Medication Authorization for Dependent Children and Youth Policy	05/17/2021	MDS2029
Urgent and Emergency Conditions Procedure	07/18/2022	MDS2031
Nursing Staff Orientation Protocol	05/17/2021	NUR2101
Control and Organization of the Standard Practice Manual (SPM) Policy	05/17/2021	BOP3001
Requests to Modify Standard Practice Manual Procedure	10/20/2021	BOP3002
Organization of the Department	05/17/2021	BOP3003
Department Vision, Mission and Values Policy	05/17/2021	BOP3004
Communications Procedures	05/17/2021	BOP3005
Incoming Mail – Departmental	05/17/2021	BOP3006
Public Information and Media Release Policy	05/17/2021	BOP3007
Paid Advertising Procedure – General	05/17/2021	BOP3009
Legal Opinion from County Counsel	05/17/2021	BOP3010
Legislative Activities	05/17/2021	BOP3011
Reimbursement for Travel and Related Expenses	05/17/2021	BOP3012
Travel Procedure	05/17/2021	BOP3013
Benefits Team Policy	05/17/2021	BOP3014
Benefits Team Procedure	05/17/2021	BOP3014-1
Vehicle Use Policy	05/17/2021	BOP3015
Vehicle Use Procedure	05/17/2021	BOP3015-1
Maintenance – Plant & Equipment	05/17/2021	BOP3016
Purchasing Procedure	05/17/2021	BOP3017
Use of Supplies and Equipment/Notification of Loss or Damage	05/17/2021	BOP3018
Furniture and Equipment Relocation Procedure	05/17/2021	BOP3019
Surplus Inventory	05/17/2021	BOP3020
Assignment of Pagers to Divisions/Programs and Staff	05/17/2021	BOP3021
Cellular Phones	05/17/2021	BOP3022
Budget Development and Changes	05/17/2021	BOP3023
Petty Cash	05/17/2021	BOP3024
Facility Physical Security and Access Control Policy	05/17/2021	BOP3025
Facility Physical Security and Access Control Procedures	05/17/2021	BOP3025-1
Billing and Collection for Treatment Services Policy	05/17/2021	BOP3027
Gifts and Donations Policy	05/17/2021	BOP3029
Gifts and Donations Procedure	05/17/2021	BOP3029-1
Prepaid Cards Policy	05/17/2021	BOP3030
Prepaid Cards Procedure	05/17/2021	BOP3030-1
Guidelines for Promotional, Educational, and/or Informational Materials	05/17/2021	BOP3031
DBH Review Panel for Promotional, Educations, and/or Informational Materials	05/17/2021	BOP3032
Review of Promotional, Educational and/or Informational Materials Procedure	05/17/2021	BOP3032-1
Assignment, Closure, Merger or Relocation of Clinics Policy	05/17/2021	BOP3033
Closure of DBH Contract Provider Procedure	05/17/2021	BOP3033-1
Assignment of DBH Contract Provider Procedure	05/17/2021	BOP3033-2
Merger of DBH Contract Provider Procedure	05/17/2021	BOP3033-3
Relocation of Clinic Procedure	05/17/2021	BOP3033-4
Employee Recognition Policy	05/17/2021	BOP3037
Telecommunication Devices Policy	05/17/2021	BOP3040
Telecommunication Devices Procedures	05/17/2021	BOP3040-1
Medi-Cal Claim Certification of Authenticity Policy	05/17/2021	BOP3042
Web Blast Policy	06/22/2022	BOP3045
Web Blast Procedure	06/22/2022	BOP3045-1
Outreach Events Policy	05/17/2021	BOP3046
Outreach Events Procedure	05/17/2021	BOP3046-1
Approval for Filling Vacancies	05/17/2021	HR4002
Advertising Procedures – Employment	05/17/2021	HR4003
New Hire Policy	05/17/2021	HR4004
Employee Separation Procedure	05/17/2021	HR4006
Work Schedules Policy	05/17/2021	HR4007
Intra-Department Reassignment Policy (Supersedes-Employee Reassignment Requests)	05/17/2021	HR4008
Intra-Department Reassignment Procedure	05/17/2021	HR4008-1
Employment Physicals	05/17/2021	HR4009
Clinical Therapists Reassignment Request	05/17/2021	HR4010
Waiver for Pre-Licensed/Out-of-State Licensed Ready Psychologists	01/25/2022	HR4011
Registration and Licensure Requirements for Clinical Therapists	05/17/2021	HR4012
Volunteer Policy	05/17/2021	HR4013
Volunteer Request and Registration Procedure	05/17/2021	HR4013-1
Non-Discrimination / Equal Employment Opportunity	05/17/2021	HR4015
Dress and Grooming Policy	05/17/2021	HR4016
Disability Discrimination Complaints	05/17/2021	HR4017
Personnel Records	05/17/2021	HR4018
Telephone Calls – Personal	05/17/2021	HR4019
Smoking and Tobacco Use Policy	05/17/2021	HR4020
Time and Attendance Form – How to Complete	05/17/2021	HR4021
Time and Attendance Correction	05/17/2021	HR4021-1
Vacation Leave – Request	05/17/2021	HR4023
Overtime Policy	05/17/2021	HR4025
Position Transfer Reassignment & Borrowing Policy	05/17/2021	HR4026
Position Transfer Reassignment & Borrowing Procedure	05/17/2021	HR4026-1
Tuberculosis Screening Policy	05/17/2021	HR4030
Tuberculosis Screening Procedure	05/17/2021	HR4030-1
Procedure for Purchasing Computer Equipment	05/17/2021	IT5001
Request for Information Technology Support Procedure	05/17/2021	IT5002
Internet Access policy	05/17/2021	IT5003
Computer and Network Appropriate Use Policy	05/17/2021	IT5004
Electronic Mail Use Policy	05/17/2021	IT5005
Risk Assessment Policy	05/17/2021	IT5007
Device and Media Controls Policy	05/17/2021	IT5008
User- I.D. and Password Policy	05/17/2021	IT5009
Superseded by myAvatar User Account Creation and Reinstatement Procedure	12/15/2021	IT5012-5
Medi-Cal Site Certification Policy	07/22/2022	QM6002
Medi-Cal Site Certification Procedure	07/22/2022	QM6002-1
QShort-Doyle and Short-Doyle/Medi-Cal Clinic Change of Ownership or Location	05/17/2021	QM6003
Research and Evaluation Functions	05/17/2021	QM6004
Research Review Committee	05/17/2021	QM6005
Requesting an Initial Choice of Provider or Change of Provider Procedure	07/19/2022	QM6006-1
Requesting an Initial Choice of Provider or Change of Provider Policy	07/19/2022	QM6006
Credentialing Policy	05/17/2021	QM6008
Credentialing Procedure	05/17/2021	QM6008-1
Quality Management Committee Membership/Participation	05/17/2021	QM6009
Written Informing Materials Policy	05/17/2021	QM6012
Post State Audit Procedures	05/17/2021	QM6014
Pre State Chart Audit Responsibilities & Procedures	05/17/2021	QM6015
Procedure for Submission of Chart Documentation and Charge Data Invoices (CDIs)	05/17/2021	QM6016
Billing Guidelines for Quality Assurance Activities	05/17/2021	QM6019
Outpatient Chart Audit – Site Review Policy	05/17/2021	QM6020
Investigating and Reporting Death of a DBH Client	05/17/2021	QM6021
Quality of Care Referral Policy	05/17/2021	QM6022
Quality of Care Referral Procedure	05/17/2021	QM6022-1
SAMHSA Block Grant-Annual Program Review Procedure	05/17/2021	QM6024
Fee-For Service Credentialing Procedure	05/17/2021	QM6026
DBH Provider Directories Policy	05/17/2021	QM6027
Grievance and Appeal Policy	05/17/2021	QM6029
Grievance Procedure	05/17/2021	QM6029-1
State Hearing Procedure	05/17/2021	QM6029-2
Standard and Expedited Resolution of Appeals Procedure	05/17/2021	QM6029-3
NOABD Procedure	05/17/2021	QM6029-4
Research Policy	05/17/2021	QM6032
Service Delivery Definition Policy	05/17/2021	QM6036
Consistency in Inpatient and Outpatient Utilization Review and Authorization Practices Policy	07/19/2022	QM6038
Consistency in Inpatient Utilization Review and Authorization Practices Procedure	07/19/2022	QM6038-1
Consistency in Outpatient Utilization Review and Authorization Practices Procedure	07/19/2022	QM6038-2
MHP Point of Authorization Plan for Inpatient Psychiatric Hospitalization Protocol	05/17/2021	QM6039
Tier Transition Protocol	05/17/2021	QM6040
Timely Access Procedure	08/18/2022	QM6041-1
Timely Access Policy	07/19/2022	QM6041
Network Adequacy Procedure	05/17/2021	QM6043-1
Out of Network Policy	07/18/2022	QM6044
Out of Network Access Procedure	07/18/2022	QM6044-1
24/7 Access Line Requirements Policy	07/20/2022	QM6045
24/7 Access Line Requirements Procedure	07/20/2022	QM6045-1
Service Availability Policy	07/19/2022	QM6046
Selection and Retention of Network Provider Policy	05/17/2021	QM6048
Department Liability for Employees and Volunteers’ Action Outside Work	05/18/2021	SFT7002
Bomb Threat Procedure	05/18/2021	SFT7005
Earthquake Procedures	05/18/2021	SFT7006
Disaster and Mass Casualty Policy	05/18/2021	SFT7007
Air Pollution Emergency Episode Plan	05/18/2021	SFT7008
Assaultive Behavior Plan (ABP) Policy	05/18/2021	SFT7009
Assaultive Behavior Plan (ABP) Procedure	05/18/2021	SFT7009-1
Possession of a Weapon Policy	05/18/2021	SFT7010
Possession of a Weapon Procedure	05/18/2021	SFT7010-1
Safety and Emergency Coordination Policy	05/18/2021	SFT7011
Electrical Safety Policy: Personal Appliances	05/18/2021	SFT7012
Safety in the Field Procedure	05/18/2021	SFT7013
Threats Against Federal or State Officials Policy	05/18/2021	SFT7014
Threats and Assault on DBH Staff Policy	05/18/2021	SFT7015
Threats and Assault on DBH Staff Procedure	05/18/2021	SFT7015-1
Special Incident Reporting Procedure – Client Related	05/18/2021	SFT7016
How to Report an Incident	05/18/2021	SFT7017
Hazard Reporting Policy	05/18/2021	SFT7018
Vehicle Accidents Reporting Procedure	05/18/2021	SFT7019
Occupational Injury or Illness Reporting Procedure	05/18/2021	SFT7020
Employee General Safety Policy	05/18/2021	SFT7021
Emergency Action Plan (EAP) Policy	05/18/2021	SFT7022
Disaster Equipment Security Policy	05/18/2021	SFT7023
Kiln Policy	05/18/2021	SFT7024
Local Community Crisis Incident Response Procedure	05/18/2021	SFT7028
Office Ergonomics Intervention Program Policy	05/18/2021	SFT7029
Interagency Communication of Unusual Events Procedure	05/18/2021	SFT7032
Education and Training Policy	10/19/2021	TRA8001
Executive Training Committee Policy	05/18/2021	TRA8003
Training Payment Procedure	05/18/2021	TRA8004
Training Attendance Policy	05/18/2021	TRA8005
Training Tuition Reimbursement Policy	05/18/2021	TRA8006
Training Tuition Reimbursement Procedure	05/18/2021	TRA8006-1
Training Coordination Policy	05/18/2021	TRA8008
Training Coordination Procedure	09/29/2021	TRA8008-1
License Exam Prep Program Policy	05/18/2021	TRA8010
Bilingual Certification Policy	08/24/2021	HR4031
Request for Second Opinion QM6053 New!	08/24/2021	QM6053
Request for Second Opinion Procedure QM6053-1 New!	08/24/2021	QM6053-1
SUDRS Master Provider File Procedure	09/07/2021	SUDRS0238
Substance Use Disorder and Recovery Services Policy	09/07/2021	SUDRS0207
Substance Use Disorder and Recovery Services Procedure	09/07/2021	SUDRS0207-1
Naloxone Intranasal Distribution Policy	09/07/2021	MDS2032
Naloxone Intranasal Distribution Procedure	09/07/2021	MDS2032-1
Advance Health Care Directive	09/23/2021	COM005
Remote Access Policy	09/28/2021	IT5006
Client Tuberculosis (TB) Testing and Services Policy	11/03/2021	SUDRS0219
Client Tuberculosis (TB) Testing and Services Procedure	11/03/2021	SUDRS0219-1
myAvatar Electronic Health Records Policy	12/15/2021	IT5012
myAvatar User Account Request Procedure	12/15/2021	IT5012-1
myAvatar User Account Creation and Reinstatement Procedure	12/15/2021	IT5012-2
myAvatar User Account Modification Procedure	12/15/2021	IT5012-3
myAvatar User Account Deactivation Procedure	12/15/2021	IT5012-4
Criteria for Beneficiary Access to SMHS Medical Necessity and other Requirements	06/14/2022	QM6054
Medication Support Only Case Policy	06/22/2022	MDS2009
No Wrong Door for Mental Health Services Policy	07/01/2022	QM6055
Test Call Policy	07/20/2022	QM6057

Name	Modified Date	Notice Number
Evaluation Code Changes	01/21/2021	IN 20-09
Revised Mental Health Co-Staffing Chart Documentation a	07/01/2020	IN 20-07
Personal Protective Equipment (PPE) for DBH Programs	06/01/2020	IN 20-06
Quality Management Chart Documentation Guidance due to	05/01/2020	IN 20-05
A1 DUI Guidance due to COVID-19	05/01/2020	IN 20-05
A2 NTP Guidance due to COVID-19	05/01/2020	IN 20-05
Administration Guidance due to COVID-19	05/01/2020	IN 20-05
New Classification of Other Qualified Providers	02/01/2020	IN 20-02
Suicide Prevention Training Requirement	01/01/2020	IN 20-01
Coronavirus (COVID-19) Information for DBH Workforce	08/11/2021	IN 20-04
Mental Health Consumer Perception Survey – Spring 2019	08/12/2021	IN 19-01
DMC-ODS UCLA Treatment Perception Survey-October 2019	08/12/2021	IN 19-02
Notice of Changes to EPSDT Data Collection Requirements	08/12/2021	IN 19-04
Approved Abbreviations New!	08/12/2021	IN 19-05
Editing Notice of Adverse Benefit Determination (NOABD)	08/12/2021	IN 19-06
Mental Health Consumer Perception Survey-Fall 2019 New!	08/12/2021	IN 19-07
Consolidation of Electronic Signature (E-Signature)	08/12/2021	IN 19-08
New Medicare Beneficiary Identifier (MBI) New!	08/12/2021	IN 19-09
Network Adequacy Requirements and Deadline (03/01/2018)	08/12/2021	IN 18-01
Updated Authorization to Release Protected Health Info	08/12/2021	IN 18-02
Child and Adolescent Needs and Strengths (CANS)(PSC-35)	08/12/2021	IN 18-03
UCLA Treatment Perceptions Survey Information (9/20/18)	08/12/2021	IN 18-04
Mental Health Consumer Perception Survey – Fall 2018	08/12/2021	IN 18-05
Office Configuration Safety Standards (12/18/2018) New!	08/12/2021	IN 18-06
Standing Order Requirement for Administering NARCAN	08/12/2021	IN 18-08
Disaster Response Requirements (02/01/2017) New!	08/12/2021	IN 17-01
Revised Child/Adolescent Psychiatric Evaluation CLP014	08/12/2021	IN 17-02
SIMON Update (03/01/2017) New!	08/12/2021	IN 17-03
Regulations Regarding Welfare and Institutions Code WIC	08/12/2021	IN 17-05
CLP015-1 Child/Adolescent Assessment-CANS-SB 05/02/2017	08/12/2021	IN 17-07
Implementation of the Diagnostic and Statistical Manual	08/12/2021	IN 17-09
Medicaid Managed Care Final Rule Implementation	08/12/2021	IN 17-10
Confidentiality Statement Requirement for Safeguarding	08/12/2021	IN 17-11
Oath of Confidentiality (Contractors)	01/14/2022	IN 17-11 Appendix A
Implementation of Title Change of Marriage and Family	08/12/2021	IN 17-12
Psychiatric Mental Health Nurse Practitioners	08/12/2021	IN 17-14
New Mental Health Procedure Codes (10/13/2016)	08/12/2021	IN 16-03
Outpatient Chart Manual and Scope of Practice Guide	08/12/2021	IN 16-02
Revised Medicare Certification Requirement (01/29/2016)	08/12/2021	IN 11-04
Electronic Mail (e-mail) Encryption (11/19/2015)	08/12/2021	IN 15-04
Contact by Outside State or Federal Agencies	08/12/2021	IN 14-12
Breining Institute Accreditation Termination	08/12/2021	IN 14-11
Guidelines for Day Treatment Intensive	08/12/2021	IN 14-10
Updates to the Scope of Practice and Billing Guide	08/12/2021	IN 14-06
Updated DBH Billing Forms and Reference Materials	08/12/2021	IN 14-09
Medi-Cal Expansion-Determining Tier III Service	08/12/2021	IN 14-05
ICD-10 Implementation Delayed (04/03/2014)	08/12/2021	IN 14-08
Medicare Updates Regarding ICD-10 (02/20/2014)	08/12/2021	IN 14-01
Medi-Cal Expansion (02/11/2014)	08/12/2021	IN 14-03
Updates to the Scope of Practice and Billing Guide	08/12/2021	IN 14-02
Updates to the Lanterman-Petris-Short (LPS) Act	08/12/2021	IN 13-13
Diagnostic and Statistical Manual of Mental Disorder	08/12/2021	IN 13-15
Discontinuance of Procedure Code 365 (11/05/2015)	08/12/2021	IN 15-02
Non-use of Blood Glucometers (06/02/2015)	08/12/2021	IN 15-01 Non-use of Blood Glucometers (06/02/2015)
Marriage and Family Therapist Intern Experience	08/12/2021	IN 13-10
Board of Behavioral Sciences (BBS) Amendments	08/12/2021	IN 13-09
Care Necessity Form – Revision (09/13/2013)	08/12/2021	IN 13-08
Medicare Administrative Contract Transition 07/15/2013	08/12/2021	IN 13-07
Mental Health Plan (MHP) Contract Clarifications	08/12/2021	IN 13-05
Client Index Number (CIN) Policy Enforcement 07/02/2013	08/12/2021	IN 13-06
DBH Library Protocol (05/08/2013)	08/12/2021	IN 13-03
Accreditation of Certifying Organizations (04/30/2013)	08/12/2021	IN 13-04
Disclosure of Ownership (03/18/2013)	08/12/2021	IN 13-01 Disclosure of Ownership (03/18/2013)
Changes in Charge Data Invoice (CDI) Codes (12/27/2012)	08/12/2021	IN 12-05
Outpatient Chart Manual/Initial Contact Form 12/20/2012	08/12/2021	IN 12-06
License Denied or Suspended for Failure to Pay Taxes	08/12/2021	IN 12-02
Clinical Re-Assessment (07/24/2012)	08/12/2021	IN 12-03
Requirements for Lactation Accommodations (01/06/2012)	08/12/2021	IN 12-01
Board Referral of Matters to County Staff (10/26/2011)	08/12/2021	IN 11-17
Authorization of Release of Protected Health Info	08/12/2021	IN 11-13
Sharing of Protected Health Information relating to MH	08/12/2021	IN 11-11
Medi-Cal Claims Processing Requirements When Other	08/12/2021	IN 11-10
Scope of Practice and Billing Guide (05/17/2011)	08/12/2021	IN 11-07
Updates to Universal Chart Data Invoice (CDI) Codes	08/12/2021	IN 11-06
Outpatient Chart Manual (OCM) Revision (05/09/2011)	08/12/2021	IN 11-08
Assembly Bill (AB) 583 (01/18/2011)	08/12/2021	IN 11-02
Medi-Cal Eligibility System (MEDS) (01/18/2011)	08/12/2021	IN 11-01
Generic Medication (11/19/2010)	08/12/2021	IN 10-15
Sanctions for Certification of Excluded, Suspended	08/12/2021	IN 10-14
JAG-OTP Funds (08/11/2010)	08/12/2021	IN 10-10
AMA Notice To Consumer	10/07/2021	IN 10-09
Adhering to Educational Regulations (05/26/2010)	08/12/2021	IN 10-08
Providing Written Communication to Consumers/Family	08/12/2021	IN 10-07
Medicare: Forms Update & Review Process (03/01/2010)	08/12/2021	IN 10-05
Certification of Alcohol and Other Drug (AOD) Counselor	08/12/2021	IN 10-04
Simon Update for Short Doyle/Medi-Cal Phase II	08/12/2021	IN 10-03
Approval of Promotional, Educational and/or Information	08/12/2021	IN 09-11
Outpatient Chart Manual (04/08/2009)	08/12/2021	IN 09-10
Referral of Clients from Contract Agencies	08/12/2021	IN 09-06
Health Family SED Services Policy/Procedures 02/11/2009	08/12/2021	IN 09-03
Practice and Billing Guide (02/01/2009)	08/12/2021	IN 09-02
Outpatient Chart Manual (OCM) Changes (01/26/2009)	08/12/2021	IN 09-01
Inpatient Claims for Medi-Cal Recipients with other	08/12/2021	IN 08-07
Deficit Reduction Act Compliance (11/24/2008)	08/12/2021	IN 08-04
Incentive Cards Procedure and Controls (12/10/2007)	08/12/2021	IN 07-05
CDPH Orders for Behavioral Health Facilities & Workers	09/10/2021	IN 21-03
Flexibilities for Medicare Telehealth Services	12/01/2021	IN 21-02
Chart Entry to Address Provider Professional Credentials	12/02/2021	IN 21-04

Name	Modified Date	Modified By
myAvatar Chart Documentation Procedural Changes (IIN 21-002)		IIN 21-002
Network Adequacy Certification Tool (NACT) (07/01/2020)	08/12/2021	IIN 20-001
Ergonomic Assessment Level (12/12/2018) New!	08/12/2021	IIN 18-001
e-Prescribing Chart Documentation (12/07/2016) New!	08/12/2021	IIN 16-001
Reporting Medical Conditions and Communicable Diseases	08/12/2021	IIN 16-002
Pill Organizers for DBH Clients (11/06/2015)	08/12/2021	IIN 15-003
ICD-10 Diagnosis and Procedure Code Transition	08/12/2021	IIN 15-002
State Requirements for Treatment Authorization Requests	08/12/2021	IIN 14-004
Electrical Safety: Personal Appliances (04/11/2014)	08/12/2021	IIN 14-002
Medication Policy and Procedure (11/20/2013)	08/12/2021	IIN 13-002
Microsoft LYNC (02/19/2013)	08/12/2021	IIN 12-006
Prepaid Debit Cards/Bus Pass Continuous Written Log	08/12/2021	IIN 12-004
Email Encryption (06/30/2011)	08/12/2021	IIN 11-002
Use of Electronic Signatures (04/22/2010)	08/12/2021	IIN 10-003
Disaster and Safety Unit (04/01/2010)	08/12/2021	IIN 10-002
Red Flags Rule (05/04/2009)	08/12/2021	IIN 09-002
Use of Episode Closing Codes (03/02/2009)	08/12/2021	IIN 09-001

Type	Name	Modified Date	Program and Number	Actions
	Mode and Service Function Information	12/20/2021	Fiscal
	PEI Modes of Service	12/20/2021	Fiscal