Departmental Forms Home ›Documents › Departmental Forms Type Name Modified Date Program and Number Actions NAR Your Rights (Vietnamese) 03/01/2025 QM025_V NAR Your Rights (Mandarin Large Print) 03/01/2025 QM025_M NAR Your Rights (Mandarin) 03/01/2025 QM025_M NAR Your Rights (Spanish Large Print) 03/01/2025 QM025_S NAR Your Rights (Spanish) 03/01/2025 QM025_S Modification Notice (NOABD) (Vietnamese Large Print) 03/01/2025 QM030_V NAR Your Rights (Vietnamese Large Print) 03/01/2025 QM025_V NAR Your Rights (Vietnamese Large Print) 03/01/2025 QM025_V NAR Your Rights (Spanish Large Print) 03/01/2025 QM025_S NAR Your Rights (Mandarin) 03/01/2025 QM025_M NAR Your Rights (Mandarin Large Print) 03/01/2025 QM025_M Bomb Threat Checklist 08/25/2026 SFT050 Coding Division Inquiry Form 08/24/2026 COM049 Standard Practice Manual Request Form 04/21/2026 BOP013 Benefit Determination Upheld (Mandarin Large Print) 03/01/2025 QM031_M Adverse Benefit Determination Upheld (Mandarin) 03/01/2025 QM031_M Adverse Benefit Determination Upheld (Spanish Large Print) 03/01/2025 QM031_S Adverse Benefit Determination Upheld (Spanish) 03/01/2025 QM031_S Adverse Benefit Determination Upheld (Large Print) 03/02/2025 QM031 Adverse Benefit Determination Upheld 03/01/2025 QM031 NAR Your Rights 03/01/2025 QM025 Language Assistance Taglines 03/03/2025 QM027 Letter of Support Cover Sheet 06/18/2026 BOP043 Access to Medical Records Request (Vietnamese) 03/24/2026 COM021_V Adverse Benefit Determination Upheld (Vietnamese Large Print) 03/01/2025 QM031_V Adverse Benefit Determination Upheld (Vietnamese) 03/01/2025 QM031_V Access to Medical Records Request (Mandarin) 03/24/2026 COM021_M Clozaril Side Effect Checklist 05/05/2026 MDS024 Mobile Crisis Assessment Tool (MCAT) 05/01/2026 CLP056 BHBH $119 Hotel/Motel Monthly Summary-Claim for Reimbursement 11/10/2025 ADT007-D Duty to Protect Intended Victim Letter (Printable) (Mandarin) 02/23/2026 CLP063_M Protect Intended Victim Letter (Printable) (Vietnamese) 02/23/2026 CLP063_V Duty to Protect Intended Victim Letter (Printable) (Spanish) 02/23/2026 CLP063_S Duty to Protect Intended Victim Letter (Printable) 06/26/2026 CLP063 Interdisciplinary Note for Justice Involved (JI) 12/08/2025 CLP069 BHBH $90 Hotel/Motel Monthly Summary-Claim for Reimbursement 11/10/2025 ADT007-C Specialty Crisis Note 02/13/2026 CLP070 Triage Transition Services (TTS) Progress Note 12/17/2025 CLP057 BHBH $85 Hotel/Motel Monthly Summary-Claim for Reimbursement 11/10/2025 ADT007-B BHBH $75 Hotel/Motel Monthly Summary-Claim for Reimbursement 11/10/2025 ADT007-A BHBH Hotel Motel Shelter Referral Voucher Form 11/10/2025 ADT006 BHBH Enhanced Shelter Referral Voucher Form 11/10/2025 ADT005 Medication Consent for Behavioral Health Condition(s) (Spanish) 12/16/2025 MDS002_S Medication Consent for Behavioral Health Condition(s) 12/16/2025 MDS002_E Medication Consent for Behavioral Health Condition(s) (Vietnamese) 12/16/2025 MDS002_V Medication Consent for Behavioral Health Condition(s) (Mandarin) 12/16/2025 MDS002_M Emergency Shelter Monthly Summary Form 11/10/2025 ADT003 Emergency Shelter Referral Voucher Form 11/10/2025 ADT002 Client Comment Card 10/24/2025 CUL010 Interpreter Feedback Form for DBH Staff 10/24/2025 CUL011 Notice to Patient Client – English 06/14/2023 MDS030 Notice to Patient Client – Spanish 06/14/2023 MDS030_S Notice to Patient Client – Mandarin 06/14/2023 MDS030_M Notice to Patient Client – Vietnamese 06/14/2023 MDS030_V Notice to Patient Client D.O. – English 06/14/2023 MDS031 Confidentiality Privacy and Security Compliance Training FAQs 04/16/2025 j1802 Notice to Patient Client D.O. – Spanish 06/14/2023 MDS031_S Notice to Patient Client D.O. – Mandarin 06/14/2023 MDS031_M Notice to Patient Client D.O. – Vietnemese 06/14/2023 MDS031_V Statement of Awareness 03/31/2023 HR003 Naloxone Distribution Project Acknowledgement Form 03/02/2023 MDS026 Naloxone Distribution Project Acknowledgement Form (Spanish) 03/02/2023 MDS026_S Enhanced CareManager (ECM) Progress Note 04/25/2025 CLP062 Naloxone Distribution Project Acknowledgement Form (Vietnamese) 03/02/2023 MDS026_V Naloxone Distribution Project Acknowledgement Form (Mandarin) 03/02/2023 MDS026_M Substance Use Screening Log 01/24/2023 SUDRS055 Notice of Privacy Practices and Acknowledgement of Receipt of Notice of Privacy Practices (Mandarin) 02/17/2026 COM004_M Tuberculosis Screening Questionnaire 05/02/2024 SUDRS059 Notice of Privacy Practices and Acknowledgement of Receipt of Notice of Privacy Practices (Spanish) 02/17/2026 COM004_S Notice of Privacy Practices and Acknowledgement of Receipt of Notice of Privacy Practices (V) 02/17/2026 COM004_V Change of Provider Request Form – 18pt. font (Spanish) 06/28/2022 QM047_S Request for Translation and Interpretation Services 06/12/2024 CUL012 Translation Service Request 08/25/2025 CUL002 Interpretation Service Request 08/25/2025 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 Delivery System Notice (NOABD) (Large Print) 03/01/2025 QM029 Delivery System Notice (NOABD) (Spanish) 03/01/2025 QM029_S Delivery System Notice (NOABD) (Spanish Large Print) 03/01/2025 QM029_S Delivery System Notice (NOABD) (Mandarin) 03/01/2025 QM029_M Delivery System Notice (NOABD) (Mandarin Large Print) 03/01/2025 QM029_M Delivery System Notice (NOABD) (Vietnamese) 03/01/2025 QM029_V Delivery System Notice (NOABD) (Vietnamese Large Print) 03/01/2025 QM029_V Notice of Grievance Resolution (Large Print) 03/01/2025 QM028 Notice of Grievance Resolution (Spanish) 03/08/2025 QM028_S Notice of Grievance Resolution (Spanish Large Print) 03/01/2025 QM028_S Notice of Grievance Resolution (Mandarin) 03/01/2025 QM028_M Notice of Grievance Resolution (Mandarin Large Print) 03/01/2025 QM028_M Notice of Grievance Resolution (Vietnamese) 03/01/2025 QM028_V Notice of Grievance Resolution (Vietnamese Large Print) 03/01/2025 QM028_V Electronic Signature Request Checklist 07/20/2026 COM043 FFS Provider Conflict of Interest/Disclosures 01/13/2026 COM047 Out of Network Services Request 07/12/2022 QM039 Beneficiary Nondiscrimination Notice (Spanish) 03/01/2025 QM026_S Beneficiary Nondiscrimination Notice (Spanish Large Print) 03/01/2025 QM026_S Beneficiary Nondiscrimination Notice (Mandarin) 03/01/2025 QM026_M Beneficiary Nondiscrimination Notice (Mandarin Large Print) 03/01/2025 QM026_M Beneficiary Nondiscrimination Notice (Vietnamese) 03/01/2025 QM026_V Beneficiary Nondiscrimination Notice (Vietnamese Large Print) 03/01/2025 QM026_V Beneficiary Nondiscrimination Notice (Large Print) 03/01/2025 QM026 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 05/10/2022 SUDRS044 Consent for SUD Care Coordination Services (Spanish) 06/26/2026 SUDRS035_S Care Coordination Needs Determination Screening Tool (English) 06/26/2026 SUDRS036_E SUD Care Coordination Needs Determination Screening Tool (Spanish) 06/26/2026 SUDRS036_S SUD Care Coordination Plan (English) 06/01/2023 SUDRS037_E SUD Care Coordination Plan (Vietnamese) 06/01/2023 SUDRS037_V SUD Care Coordination Plan (Mandarin) 06/01/2023 SUDRS037_M SUD Care Coordination Plan (Spanish) 06/01/2023 SUDRS037_S Care Coordination Discharge Summary (English) 06/26/2026 SUDRS038_E Care Coordination Discharge Summary (Spanish) 06/26/2026 SUDRS038_S CalOMS Administrative Discharge 06/26/2026 SUDRS045 CalOMS Admission 12/16/2024 SUDRS046 CalOMS Admission Instructions 06/26/2026 SUDRS047 CalOMS Standard Discharge 06/26/2026 SUDRS048 Telehealth Consent Form (Fillable) 07/31/2025 MDS042 Telehealth Consent Form (Printable) 07/31/2025 MDS042 (Printable) CalOMS Standard Discharge Instructions 06/26/2026 SUDRS049 Privacy and Security Incident Reporting Form 03/25/2026 COM042 Medi Cal Fee For Service Provider Manual 06/26/2026 MHPFFS51319 DBH Discipline – Taxonomy Codes 08/04/2026 j1802 Staff Master Worksheet Update 06/26/2026 j1802 Staff Master Worksheet 06/26/2026 j1802 Adult Screening Tool for Medi-Cal Mental Health Services 09/26/2024 DHCS 8765 A Youth Screening Tool for Medi-Cal Mental Health Services 09/26/2024 DHCS 8765 C Transition of Care Tool for Medi-Cal Mental Health Services 09/26/2024 DHCS 8765 B Mental Health Professional Licensing Waiver Request 08/30/2022 DHCS 1739 Title 22 Fair Hearing Rights 01/31/2023 SUDRS002_E Title 22 Fair Hearing Rights (Spanish) 01/31/2023 SUDRS002_S Title 22 Fair Hearing Rights (Mandarin) 01/31/2023 SUDRS002_M Title 22 Fair Hearing Rights (Vietnamese) 01/31/2023 SUDRS002_V Client Admission Agreement_V 01/13/2025 SUDRS022_V Notice of Personal Rights / Civil Rights 04/08/2026 SUDRS003_E Notice of Personal Rights / Civil Rights (Spanish) 11/27/2023 SUDRS003_S Notice of Personal Rights / Civil Rights (Mandarin) 11/27/2023 SUDRS003_M Client Admission Agreement 01/13/2025 SUDRS022_E Notice of Personal Rights / Civil Rights (Vietnamese) 11/27/2023 SUDRS003_V Client Admission Agreement_M 01/04/2025 SUDRS022_M Client Admission Agreement_S 01/01/2025 SUDRS022_S Substance Use Disorder and Recovery Services Intake 06/01/2023 SUDRS025 Adult (Age 21 and Over) DMC-ODS Transition 06/26/2026 SUDRS026 Immediate Need Profile 05/06/2022 SUDRS027 Adult (21+) ASAM Level of Care Screening 05/07/2025 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) 06/26/2026 SUDRS030_E Adolescent (Age 12-17) and Young Adult ASAM Level of Care Screening 09/04/2024 SUDRS031 Adolescent (age 12-17) And Young Adult (age 18-20) Dmc-ods Transition New! 05/10/2021 SUDRS033 SUD Referral 11/15/2023 SUDRS034 Recovery Services Plan 05/10/2021 SUDRS039 CalOMS Admission-Outpatient 12/16/2024 SUDRS051 ASAM Level of Care 03/07/2024 SUDRS042 Therapeutic Foster Care (TFC) Prior Authorization Request 04/16/2025 CHD022 Screening Tool For Therapeutic Foster Care (TFC) Services 04/16/2025 CHD024 DBH-SUDRS CalOMS Annual Update 08/02/2024 SUDRS052 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 Possession of a Weapon Notice for Clinics 09/16/2024 SFT009 Possession of a Weapon Notice for Clinics_Vietnamese 09/16/2024 SFT009_Vietnamese Possession of a Weapon Notice for Clinics_Mandarin 09/16/2024 SFT009_Mandarin Possession of a Weapon Posted Notice for Clinics_Spanish 09/16/2024 SFT009_Spanish Community Crisis Response Teams (CCRT) Consent Letter to Parents and Adults (Mandarin) 01/21/2025 CLP060_M Community Crisis Response Teams (CCRT) Consent Letter to Parents and Adults (Vietnamese) 01/21/2025 CLP060_V Community Crisis Response Teams (CCRT) Consent Letter to Parents and Adults 01/21/2025 CLP060_E Community Crisis Response Team (CCRT) Consent Letter to Parents and Adults (Spanish) 01/21/2025 CLP060_S 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 Charge Data Correction Invoices 11/20/2024 CLP010 Universal Charge Data Invoice (Printable) 10/29/2024 CLP006 (Printable) Universal Charge Data Invoice (Fillable) 10/24/2024 CLP006 (Fillable) Client Resource Evaluation 10/24/2024 CLP012 Adult Psychiatric Evaluation (Fillable) 09/05/2024 CLP013 (Fill) Adult Psychiatric Evaluation (Printable) 09/05/2024 CLP013 (Print) Child Adolescent Psychiatric Evaluation and Update 11/13/2024 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 10/16/2024 CLP027 Services Teams Actions 09/24/2024 CLP028 Caregiver’s Authorization Affidavit 05/22/2026 CLP029 Caregiver’s Authorization Affidavit (Mandarin) 05/22/2026 CLP029_M Caregiver’s Authorization Affidavit (Vietnamese) 05/22/2026 CLP029_V Caregiver’s Authorization Affidavit (Spanish) 05/22/2026 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 Assessment/Evaluation/Crisis Form (DHCS 1801) 07/13/2026 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 Referral Summary for Referral to Managed Care Plan (MCP) 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) (Mandarin Large Print) 03/01/2025 QM024_M Your Rights Attachment (NOABD) (Spanish Large Print) 03/01/2025 QM024_S Your Rights Attachment (NOABD) (Vietnamese Large Print) 03/01/2025 QM024_V Your Rights Attachment (NOABD) (Vietnamese) 03/01/2025 QM024_V Your Rights Attachment (NOABD) (Spanish) 03/01/2025 QM024_S Your Rights Attachment (NOABD) (Mandarin) 03/01/2025 QM024_M Your Rights Attachment (NOABD) (English) 03/01/2025 QM024_E Beneficiary Nondiscrimination Notice (English) 03/01/2025 QM026_E Modification Notice (NOABD) (Vietnamese) 03/01/2025 QM030_V Modification Notice (NOABD) (Mandarin Large Print) 03/01/2025 QM030_M Modification Notice (NOABD) (Mandarin) 03/01/2025 QM030_M Modification Notice (NOABD) (Spanish Large Print) 03/01/2025 QM030_S Delivery System Notice (NOABD) 03/01/2025 QM029_E Timely Access Notice (NOABD) (Large Print) 03/01/2025 QM061 Financial Liability Notice (NOABD) (Large Print) 03/01/2025 QM078 Authorization Delay Notice (NOABD) (Large Print) 03/01/2025 QM033 Termination Notice (NOABD) (Large Print) 03/01/2025 QM059 Modification Notice (NOABD) (Large Print) 03/01/2025 QM030 Modification Notice (NOABD) (English) 03/01/2025 QM030_E Modification Notice (NOABD) (Mandarin) 11/15/2023 QM030_M Modification Notice (NOABD) (Spanish) 03/01/2025 QM030_S Change Order Request Routing Slip 02/12/2025 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_Et Quality Assurance Audit At Annual Point 05/11/2021 QM056 Medication Monitoring Questionnaire 05/11/2021 QM057 Denial Notice (NOABD) (Vietnamese) 11/15/2023 QM058_V Denial Notice (NOABD) (Mandarin) 11/15/2023 QM058_M Denial Notice (NOABD) 03/01/2025 QM058_E Denial Notice (NOABD) (Spanish) 11/15/2023 QM058_S Termination Notice (NOABD) (English) 03/01/2025 QM059_E Termination Notice (NOABD) (Spanish) 03/01/2025 QM059_S Termination Notice (NOABD) (Spanish Large Print) 03/02/2025 QM059_S Termination Notice (NOABD) (Mandarin) 03/01/2025 QM059_M Termination Notice (NOABD) (Mandarin Large Print) 03/01/2025 QM059_M Termination Notice (NOABD) (Vietnamese) 03/01/2025 QM059_V Termination Notice (NOABD) (Vietnamese Large Print) 03/01/2025 QM059_V Timely Access Notice (NOABD) 03/01/2025 QM061_E Timely Access Notice (NOABD) (Mandarin) 03/01/2025 M061_M Timely Access Notice (NOABD) (Mandarin Large Print) 03/01/2025 QM061_M Timely Access Notice (NOABD) (Spanish) 03/01/2025 QM061_S Timely Access Notice (NOABD) (Spanish Large Print) 03/01/2025 QM061_S Timely Access Notice (NOABD) (Vietnamese) 03/01/2025 QM061_V Timely Access Notice (NOABD) (Vietnamese Large Print) 03/01/2025 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 Notice of Appeal Resolution (Vietnamese Large Print) 03/01/2025 QM032_V Notice of Appeal Resolution (Vietnamese) 03/01/2025 QM032_V Notice of Appeal Resolution (Spanish Large Print) 03/01/2025 QM032_S Notice of Appeal Resolution (Spanish) 03/01/2025 QM032_S Notice of Appeal Resolution (Mandarin Large Print) 03/01/2025 QM032_M Notice of Appeal Resolution (Mandarin) 03/01/2025 QM032_M Notice of Appeal Resolution (Large Print) 03/01/2025 QM032 Notice of Appeal Resolution 03/01/2025 QM032_E Financial Liability Notice (NOABD) 03/01/2025 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 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) Mandarin 06/02/2025 COM001_M Authorization to Release Protected Health Information (PHI) (Spanish) 06/02/2025 COM001_S Authorization to Release Protected Health Information (PHI) (Vietnamese) 06/02/2025 COM001_V Code of Conduct 05/21/2026 COM003 Notice of Privacy Practices and Acknowledgement of Receipt of Notice of Privacy Practices 02/17/2026 COM004_E 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_Et 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 Access to Medical Records Request 03/24/2026 COM021 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 01/29/2025 COM020 Access to Medical Records Request (Spanish) 03/24/2026 COM021_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 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 – Spanish 11/14/2024 COM038_S ACA 1557 Grievance Form 11/14/2024 COM038 Aca 1557 Grievance Form (spanish) 05/11/2021 COM038_S Electronic Signature Agreement and E-Signature and Provider Signature List 06/17/2026 COM039 AB2275 Flow Chart 01/29/2025 PR005 Notice of Patients' Entitlement to a Certification Review Hearing 01/29/2025 PR003 06/26/2026 j1802 06/26/2026 j1802 myAvatar Policy & Procedure Acknowledgment Form 03/26/2025 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 09/22/2022 COM030_E Request for Restriction of Confidential Communication (Spanish) 09/26/2022 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 Medical/Behavioral Health Clearance 05/01/2024 SUDRS024 Payment Denial Notice (NOABD) 03/01/2025 QM060_E Payment Denial Notice (NOABD) (Spanish) 03/01/2025 QM060_S Payment Denial Notice (NOABD)) (Spanish Large Print) 03/01/2025 QM060_S Payment Denial Notice (NOABD) (Mandarin) 03/01/2025 QM060_M Payment Denial Notice (NOABD) (Mandarin Large Print) 03/01/2025 QM060_M Payment Denial Notice (NOABD) (Vietnamese) 03/01/2025 QM060_V Payment Denial Notice (NOABD) (Vietnamese Large Print) 03/01/2025 QM060_V Your Rights Attachment (NOABD) (Large Print) 03/01/2025 QM024 NAR Your Rights (Large Print) 03/01/2025 QM025 Payment Denial Notice (NOABD) (Large Print) 03/01/2025 QM060 Authorization Delay Notice (NOABD) (Mandarin) 03/01/2025 QM033_M Authorization Delay Notice (NOABD) (Mandarin Large Print) 03/01/2025 QM033_M Authorization Delay Notice (NOABD) (Spanish) 03/01/2025 QM033_S Authorization Delay Notice (NOABD) (Spanish Large Print) 03/01/2025 QM033_S Authorization Delay Notice (NOABD) (Vietnamese) 03/01/2025 QM033_V Authorization Delay Notice (NOABD) (Vietnamese Large Print) 03/01/2025 QM033_V Authorization Delay Notice (NOABD) 03/01/2025 QM033_E Grievance and Appeal Timely Resolution Notice (NOABD) 03/01/2025 QM062_E Grievance and Appeal Timely Resolution Notice (Spanish) 11/22/2021 QM062_S Unusual Occurrence/Incident Report 04/07/2022 QM053 Charge Data Invoice (Fillable) 10/24/2024 CLP009 (Fillable) Charge Data Invoice (Printable) 10/24/2024 CLP009 (Printable) Termination of Provider Notice Template – Mandarin 05/22/2024 CLP045 Termination of Provider Notice Template – Vietnamese 05/22/2024 CLP045 Termination of Provider Notice Template 05/11/2022 CLP045 Adult (21+) ASAM Triage Level of Care Screening 05/05/2022 SUDRS043 Consent for SUD Care Coordination Services (English) 06/26/2026 SUDRS035_E Termination of Provider Notice Template_Spanish 05/25/2022 CLP045_S Notice of Grievance Resolution 03/01/2025 QM028_E 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 Pre-Licensed/Out-of-State Licensed Psychologists Statement of Awareness for Continued Employment 08/30/2022 HR006 Non-Medication Resource Log and Instructions 07/19/2023 MDS032 Contingency Management: Recovery Incentives Program Consent Form 08/06/2024 SUDRS054 Contingency Management: Recovery Incentives Program Consent Form (Spanish) 01/05/2024 SUDRS054 SUDRS058 Discharge Summary 01/05/2024 SUDRS058 SUDRS Discharge Plan_E 01/05/2024 SUDRS057 SUDRS057_V SUDRS Discharge Plan (Vietnamese) 01/05/2024 SUDRS057_V SUDRS057_S SUDRS Discharge Plan (Spanish) 01/05/2024 SUDRS057_S SUDRS057_M SUDRS Discharge Plan (Mandarin) 01/05/2024 SUDRS057_M Contingency Management: Recovery Incentives Program Consent Form (Vietnamese) 01/05/2024 SUDRS054 Contingency Management: Recovery Incentives Program Consent Form (Mandarin) 01/05/2024 SUDRS054 Electroconvulsive Therapy (ECT) Referral Form 01/17/2024 MDS040 Controlled Substance Count Sheet 05/16/2024 MDS041 Trainee Statement of Awareness 04/17/2024 HR025 06/26/2026 j1802 Authorization to Release Protected Health Information (PHI) English 06/26/2026 COM001_E Notice to Clients – Licensed Providers 06/25/2025 CLP067 Notice to Clients – Unlicensed Providers 06/25/2025 CLP068 Client Health Questionnaire and Initial Screening Questions 06/11/2025 SUDRS060 Notice to Clients – Unlicensed Providers (Mandarin) 06/25/2025 CLP068_M Notice to Clients – Unlicensed Providers (Spanish) 06/25/2025 CLP068_S Notice to Clients – Unlicensed Providers (Vietnamese) 06/25/2025 CLP068_V Notice to Clients – Licensed Providers (Spanish) 06/25/2025 CLP067_S Notice to Clients – Licensed Providers (Vietnamese) 06/25/2025 CLP067_V Notice to Clients – Licensed Providers (Mandarin) 06/25/2025 CLP067_M Contracted Provider 90-Day Rule for Other Healthcare Coverage (OHC) Claims Attestation 08/25/2025 BOP032 Case Study Request Form 08/15/2025 QM088 Client Resource Evaluation_Mandarin 10/24/2024 CLP012_M Client Resource Evaluation_Spanish 10/24/2024 CLP012_S Client Resource Evaluation_Vietnamese 10/24/2024 CLP012_V Contract Provider Closure Checklist 05/01/2016 BOP028 Telehealth Consent Form (Spanish) 08/28/2025 MDS042_S Telehealth Consent Form (Mandarin) 08/28/2025 MDS042_M Telehealth Consent Form (Vietnamese) 08/28/2025 MDS042_V Guidance for Detaining Persons by 5150 Application in Non LPS Designated Facility 10/07/2025 PR006 Implementation of AB2275 for San Bernardino County 10/07/2025 PR007
