County of San Bernardino - Behavioral Health - Promoting Wellness, Recovery and Resilience
  Forms  

State  
   
MH12 MH Professional Licensing Waiver Request
MH3829 Provider Update
MH3840 Legal Entity File update (LFU)
MH5120 SB785 Client Assessment
MH5121 SB785 Client Assessment Update
MH5122 SB785 Client Plan
MH5123 SB785 Progress Notes/Day Rehabilitive Services
MH5124 SB785 Progress Notes/Day Treatment Intensive Services
MH5125 SB785 Services Authorization Request (SAR)
MH5126 SB785 Organizational Provider Agrmnt for Foster Children Placed Out of County
MEDS41 MEDS Access Request
DBH712 Authorization for Issuance of Immediate Need Voucher(s)
RRF Children's Fund Referral Request Form
W-9 Form Request for Taxpayer Identification Number and Certificaiton
   
   
County  
   
ACR7973 12-7973-123, "Notice of Acquistion-Change-Disposition
ARMC_Alerts ARMC Color Codes
DBH712 Authorization for Issuance of Immediate Need Voucher(s)
RRF Children's Fund Referral Request Form
   
   
ADS Alcohol and Drug
   
ABN_Form Advance Beneficiary Notice Of Non Coverage
ADS001 Code of Professional Conduct for Drug & Alcohol Staff Acknowledgment
ADS002 Title 22 Fair Hearing Rights
ADS003_E Notice of Personal/Civil Rights
ADS003_S Notice of Personal/Civil Rights
ADS004 A & D Counselors Statement of Acknowledgement of the Req. to obtain Cert. for Continued Employment
ADS005 Counselor Certifying Obligation
ADS006 Alcohol and Drug Services Agency Evaluation
ADS008 Substance Abuse Services Client Registration Form (CalOMS)
ADS009 Substance Abuse Services Client Episode Opening Summary (CalOMS)
ADS010 Substance Abuse Services Client Episode Closing Summary (CalOMS)
ADS011 QAR Initial Review
ADS012 QAR Continued Review
ADS013 Stay Review-Justification for Continuing Service
ADS014 Waiver of Drug Medi-CAL Admission Physical
ADS015 ADS Discharge Summary
ADS016 Intensive Outpatient Criteria
ADS017 Outpatient Criteria
ADS019 Residential Criteria
ADS020 Second Service on Same Day
ADS021 Social Model Residential Detox
   
   
BOP Business Operations
   
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 and Form Request Form
BOP014 Policy, Procedure and Form Deletion Request Form
BOP015 Business Card Order Form
BOP016 Ink Stamp Order Form
BOP017 Name Plates Order Form
BOP018 County Vehicle Requisition
BOP019 Surplus Furniture Removal Memo
BOP020 Travel Request
BOP021 FPM Project Request Form
BOP022 Medi-Cal Certification Packet Approval Form
BOP023 Request for Cost Center Number
BOP024 Mode of Service Codes
BOP032 Provider Attestation 90 Day Rule
BOP033 Provider attestation 120 Day Rule
   
   
CHD Children's
   
CHD_INTER_E Children's Interagency Authorization to Exchange PHI-English
CHD_INTER_S Children's Interagency Authorization to Exchange PHI-Spanish
CHD002 Healthy Families Mental Health Response Form
CHD003 AB 2726 Financial Liability
CHD004 AB 2726 Assessment Plan
CHD005 AB 2726 Outpatient Service Plan
CHD006 AB 2726 Clinical Assessment Counseling
CHD007 AB 2726 Clinical Assessment Assaultive Behavior
CHD008 AB 2726 Clinical Assessment Residential
CHD009 AB 2726 Clinical Assessment Mental Status
CHD010 AB 2726 Clinical Assessment Fire setting
CHD011 AB 2726 IEP-Residential Placement Plan
CHD012 TBS Assessment
CHD013 TBS Risk Assessment
CHD014 TBS Referral
CHD015 TBS Notification to State DMH
CHD016 Treatment Plan - Initial Authorization
CHD017 Treatment Plan - Subsequent Authorization
CHD018 AB 2149 Intro Letter
CHD019 AB 2149 Special Incident Reporting
   
   
CLK Clerical
   
CLK003 Scheduling Template
CLK004 Schedule Change Request
CLK006 Physician Request Form
   
   
CLP Clinical Practice
   
  Episode Opening and Closing Codes
CLP001 Client Payment Agreement
CLP002 Client Episode Summary (CSI)
CLP003_E Initial Contact (CSI)
CLP003_S Initial Contact (CSI)-Spanish
CLP004 Periodic Data (CSI)
CLP005 Clinical Assessment-Adult
CLP006 CDI-Universal
CLP009 CDI-JJOP
CLP010 CDI-Correction Invoice
CLP012 Client Resource Evaluation
CLP013 Adult Psychiatric Evaluation
CLP014 Child/Adol Psychiatric Evaluation
CLP015 Child/Adol Clinical Assessment
CLP016 Physical Assessment
CLP017 Client Recovery Evaluation (Annual)
CLP018 Request to Waive Consumer's Responsibility to Pay for Medication
CLP019 Care Necessity
CLP020 Psychological Testing Referral
CLP021 Healthy Homes Assessment
CLP022 Diagnosis Form
CLP024_E Client Recovery Plan
CLP024_S Client Recovery Plan-Spanish
CLP025 Discharge Summary
CLP026 AIMS-Abnormal Involuntary Movement Scale
CLP027 Interdisciplinary (ID) Notes
CLP028 Service Team Actions
CLP029_E Care Giver Affidavit
CLP029_S Care Giver Affidavit-Spanish
CLP030 Request for Verification of Veterans Status for Mental Health Services
CLP031 Consent and Auth. to Exchange Confidential Info. Re: Veterans Status
CLP035 Medication Support Services Client Plan
   
   
COM Compliance
   
COM001-1_E Authorization for Release of PHI for Immediate Need Voucher
COM001-1_S Authorization for Release of PHI for Immediate Need Voucher_SP
COM001_E Authorization for Release of Protected Health Information (PHI) Revised!
COM001_S Authorization for Release of Protected Health Information (PHI)-Spanish
COM001_V Authorization for Release of Protected Health Information (PHI) Vietnamese
COM003 Code of Conduct Acknowledgement
COM004_E DBH Notice of Privacy Practices and Acknowledgement Form
COM004_S DBH Notice of Privacy Practices and Acknowledgement form-Spanish
COM004_V DBH Notice of Privacy Practices and Acknowledgement Form Vietnamese
COM005 Advance Directive Acknowledgement
COM006 Certification Review Hearing-Waiver of Presence
COM007 Sensitive Chart Form
COM008 Treatment Authorization Request-Adult
COM009 Treatment Authorization Request-Child
COM010 Treatment Re-Authorization Request-Adult
COM011 Treatment Re-Authorization Request-Child
COM012 Index of Confidential Information Released
COM013_E Consent of Outpatient Treatment
COM013_S Consent of Outpatient Treatment-Spanish
COM013_V Consent of Outpatient Treatment-Vietnamese
COM014_E Medical Care Authorization for Minor
COM014_S Medical Care Authorization for Minor-Spanish
COM015_E Consent for Sound & Photographic Recordings
COM016_E Consent To Record And/Or Photograph And Auth. For Use Or Disclosure Eng
COM016_S Consent To Record And/Or Photograph And Auth For Use Or Disclosure-Span
COM018_E Advance Directive Notice (Client)
COM018_S Advance Directive Notice (Client)-Spanish
COM019 Delegation of TX Consent
COM020 Conflict of Interest Disclosure
COM021_E Access to Medical Records Request
COM021_S Access to Medical Records Request - Spanish
COM022_E Response to Request to Access Medical Records
COM022_S Response to Request to Access Medical Records - Spanish
COM023_E Request to Amend Protected Health Information (PHI)
COM023_S Request to Amend Protected Health Information (PHI) - Spanish
COM024_E Response to Request to Amend Protected Health Information (PHI)
COM024_S Response to Request to Amend Protected Health Information (PHI) - Spanish
COM025 Internal Tracking of Request to Access Medical Records
COM026_E Release of Info: Patient's Right of Access to His/Her Own Medical Record-English
COM026_S Release of Info: Patient's Right of Access to His/Her Own Medical Record - Spanish
COM027 Oath of Confidentiality
COM028_E Advance Health Care Directive Brochure
COM028_S Advance Health Care Directive - (Spanish) Brochure
COM028_V Advance Health Care Directive Brochure Vietnamese
COM032_E Patient's Rights Grievance Form-English
COM032_S Patients Rights Grievance Form-Spanish
COM033 MEDS Confidentiality Statements
   
   
CUL Cultural Competency
   
CUL002 Translation Request
CUL005 Initial Contact Log
CUL006 Interpretation Service Request
CUL009 Contract Language Services Log
   
   
HR Human Resources
   
HR003 Pre-Lic MFT/MSW/PCC Stmt of Awareness
HR005 Unpaid Leave Due to No Proof of License or Registration
HR006 Pre-Lic/Out-of-State Licensed Ready Psychologists Stmt of Awareness to obtain Licensure
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
   
   
MDS Medical Services
   
MDS001 Quarterly Physician's Cabinet Inspection
MDS002_E Medication Consent Form
MDS002_S Medication Consent Form-Spanish
MDS002_V Medication Consent Form Vietnamese
MDS003 Verbal/Telephone Consent for Administration of Psychotropic Medication Form
MDS004 Letter to Parent-Legal guardian Juvenile Detention Template 1
MDS005 Letter Requesting Psychotropic Medication Template 2
MDS006 Alert Sheet for Allergies
MDS007 Outpatient Medication Record
MDS008 Medication Visit (ID Note)
MDS009 Medication Only Cases Log
MDS010 Sample Medication Log
MDS011 Patient Assistance Program Log
MDS012 Pharmaceutical Waste Log
MH12 Mental Health Professional Licensing Waiver Request
   
   
PEI Prevention and Early Intervention
   
PEI001 CDI - PEI
   
PR Patients' Rights
   
PR001 Patients' Rights Office Grievance Appeal Form
   
QM Quality Management
   
QM001 Chart Audit Tool
QM005 Annual Psychiatric Assessment Form
QM044 Change Order Request
QM045 Mode of Service/Procedure Code Change Form
QM046 State Pre-Audit Chart Review Audit Tool
QM047_E Change of Provider Request Form
QM047_S Change of Provider Request Form
QM048_E Request for Second Opinion
QM048_S Request for Second Opinion
QM049 Mental Health and Alcohol and Drug Services Agency Evaluation
QM050_E Grievance Form
QM050_S Grievance Form
QM051_E Appeal Form
QM051_S Appeal Form
QM052 Quality Assurance Review of Unexpected Deaths
QM053 Unusual Occurance/Incident Report
QM054 Clinic Supervisor Chart Audits
QM055 Program Manager Chart Audit
QM056 Quality Assurance Audit At Annual Point
QM057 Medication Monitoring Questionaire
QM058_E NOA-A
QM058_S NOA-A
QM059_E NOA-B
QM059_S NOA-B
QM060_E NOA-C
QM060_S NOA-C
QM061_E NOA-D
QM061_S NOA-D
QM062_E NOA-E
QM062_S NOA-E
QM063 MHS 902 Clinic Log
QM074 Medi-cal Site Certification Checklist
QM075 Mental Health Plan (MHP) to Medi-Cal Plan (MCP) Referral Form Revised!
   
   
TRA Training
   
TRA001 Training Coordintion Request
TRA002 LEPP Agreement Form Revised!
TRA005 Reimbursement Form New!
 

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2014 - County of San Bernardino - Department of Behavioral Health