DBH Forms - San Bernardino County, California

1 DBH FormsSTATEMH12MH Professional Licensing Waiver RequestMH5120SB785 Client AssessmentMH5121SB785 Client Assessment UpdateMH5122SB785 Client PlanMH5123SB785 Progress Notes/Day Rehabilitive ServicesMH5124SB785 Progress Notes/Day Treatment Intensive ServicesMH5125SB785 Services Authorization Request (SAR)MH5126SB785 Organizational Provider Agrmnt for Foster Children Placed Out of CountyADSA lcohol and DrugABN_FormAdvance Beneficiary Notice Of Non CoverageADS001 Code of Professional Conduct for Drug & Alcohol Staff AcknowledgmentADS002 Title 22 Fair Hearing RightsADS003_ENotice of Personal/Civil Rights ADS003_SNotice of Personal/Civil Rights ADS004A & D Counselors Statement of Acknowledgement of the Req. to obtain Cert. for Continued EmploymentADS005 Counselor Certifying ObligationADS006 Alcohol and Drug Services Agency EvaluationADS008 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 ReviewADS012 QAR Continued Review 0A0H0A1H0A2H0A3H0A4H0A5H0A6H0A7H0A8H0A9H 0A10H0A11H0A212H00A227H0A228H0A229H0A230 H0A231H0A232H0A233 HAppendix.

2 Forms Index by Program (10/09)ADS013 Stay Review-Justification for Continuing ServiceADS014 Waiver of Drug Medi-CAL Admission PhysicalADS015 ADS Discharge SummaryADS016 Intensive Outpatient CriteriaADS017 Outpatient CriteriaADS019 Residential CriteriaADS020 Second Service on Same Day ADS021 Social Model Residential DetoxBOP Business OperationsBOP001 Travel Expenditures and Claim for Payment InstructionsBOP002 Justification For Out-Of-State TravelBOP003 Visa Justification StatementBOP004 county vehicle LogBOP005 Authorization to Submit or Approve OrdersBOP006 Purchasing Procedures FlowchartBOP007 purchase RequestBOP008 Incentive Cards - Distribution to ParticipantsBOP009 Incentive Cards - LogBOP010 Incentive Cards - InventoryBOP011 purchase Request Routing Slip (Petty Cash purchases)

3 BOP012 Petty Cash Transaction Form0A0H0A1H0A2H0A3H0A4H0A5H0A6H0A7H0A8H 0A9H0A10H0A11H0A12H0A13H0A14H0A15H0A16H0 A17H0A18H0A19H0A20H0A21H0A22H0A23H0A24H0 A25H0A26H0A27H0A28H0A29H0A30H0A31H0A212H 00A227H0A228H0A229H0A230H0A231H0A232H0A2 33 HAppendix: Forms Index by Program (10/09)DBH FormsBOP Business OperationsBOP013 Policy, Procedure and form Request FormBOP014 Policy, Procedure and form Deletion Request FormBOP015 Business Card Order FormBOP016 Ink Stamp Order FormBOP017 Name Plates Order FormBOP018 county vehicle RequisitionBOP019 Surplus Furniture Removal MemoBOP020 Travel RequestBOP021 FPM Project Request FormBOP022 Medi-Cal Certification Packet Approval FormBOP023 Request for Cost Center NumberBOP024 Mode of Service CodesCHDC hildren'sCHD_INTER_EChildren's Interagency Authorization to Exchange PHI-EnglishCHD_INTER_SChildren's Interagency Authorization to Exchange PHI-SpanishCHD002 Healthy Families Mental Health Response FormCHD003AB 2726 Financial LiabilityCHD004AB 2726 Assessment Plan CHD005AB 2726 Outpatient Service PlanCHD006AB 2726 Clinical Assessment CounselingCHD007AB 2726 Clinical Assessment Assaultive BehaviorCHD008AB 2726

4 Clinical Assessment ResidentialCHD009AB 2726 Clinical Assessment Mental Status0A32H0A33H0A34H0A35H0A36H0A37H0A38 H0A39H0A40H0A41H0A42H0A43H0A44H0A45H0A46 H0A47H0A48H0A49H0A50H0A51H0A103H0A216 HAppendix: Forms Index by Program (10/09)CHD010AB 2726 Clinical Assessment Fire settingCHD011AB 2726 IEP-Residential Placement PlanCHD012 TBS AssessmentCHD013 TBS Risk AssessmentCHD014 TBS ReferralCHD015 TBS Notification to State DMHCHD016 Treatment Plan - Initial AuthorizationCHD017 Treatment Plan - Subsequent AuthorizationCHD018AB 2149 Intro LetterCHD019AB 2149 Special Incident ReportingCLKC lericalCLK003 Scheduling TemplateCLK004 Schedule Change RequestCLK006 Physician Request FormCLPC linical PracticeCLP001 Client Payment AgreementCLP002 Client Episode Summary (CSI)CLP003_EInitial Contact (CSI)CLP003_SInitial Contact (CSI)-SpanishCLP004 Periodic Data (CSI)

5 CLP005 Pre-Assessment Screening SurveyCLP006 CDI-Universal0A32H0A33H0A34H0A35H0A36H0A 37H0A38H0A39H0A40H0A41H0A42H0A43H0A44H0A 45H0A46H0A47H0A48H0A49H0A50H0A51H0A52H0A 53H0A54H0A55H0A56H0A57H0A58H0A59H0A60H0A 61H0A62H0A63H0A64H0A65H0A70H0A71H0A72H0A 73H0A74H0A103H0A216H0A234 HAppendix: Forms Index by Program (10/09)DBH FormsCLPC linical PracticeCLP007 CDI-Cal WorksCLP008 CDI-ConrepCLP009 CDI-JJOPCLP010 CDI-Correction InvoiceCLP011 Adult Clinical AssessmentCLP012 Client Resource Evaluation CLP013 Adult Psychiatric EvaluationCLP014 Child/Adol Psychiatric Evaluation CLP015 Child/Adol Clinical AssessmentCLP016 Physical AssessmentCLP017 Client Recovery Evaluation (Annual)CLP018 Request to Waive Consumer's Responsibility to Pay for MedicationCLP019 Care NecessityCLP020 Psychological Testing ReferralCLP021 Healthy Homes AssessmentCLP022 Diagnosis FormCLP024_EClient Recovery PlanCLP024_SClient Recovery Plan-SpanishCLP025 Discharge SummaryCLP026 AIMS-Abnormal Involuntary Movement ScaleCLP027 Interdisciplinary (ID)

6 NotesCLP028 Service Team ActionsCLP029_ECare Giver Affidavit0A66H0A67H0A69H0A75H0A76H0A77H0 A78H0A79H0A80H0A81H0A82H0A83H0A84H0A85H0 A86H0A87H0A88H0A89H0A90H0A91H0A92H0A93H0 A94 HAppendix: Forms Index by Program (10/09)CLP029_SCare Giver Affidavit-SpanishCLP030 Request for Verification of Veterans Status for Mental Health ServicesCLP031 Consent and Auth. to Exchange Confidential Info. Re: Veterans StatusCLP035 Medication Support Services Client PlanCOMC omplianceCOM001_EAuthorization for Release of Protected Health Information (PHI)COM001_SAuthorization for Release of Protected Health Information (PHI)-SpanishCOM002 Sample Fax Cover SheetCOM003 Code of Coduct AcknowledgementCOM004_EDBH Notice of Privacy Practices and Acknowlegement form COM004_SDBH Notice of Privacy Practices and Acknowlegement form -SpanishCOM005 Advance Directive AcknowledgementCOM006 Certification Review Hearing-Waiver of PresenceCOM007 Sensitive Chart FormCOM008 Treatment Authorization Request-AdultCOM009 Treatment Authorization Request-ChildCOM010 Treatment Re-Authorization Request-AdultCOM011 Treatment Re-Authorization Request-ChildCOM012 Index of Confidential Information ReleasedCOM013_EConsent of Outpatient TreatmentCOM013_SConsent of Outpatient

7 Treatment-Spanish0A66H0A67H0A68H0A69H0A7 5H0A76H0A77H0A78H0A79H0A80H0A81H0A82H0A8 3H0A84H0A85H0A86H0A87H0A88H0A89H0A90H0A9 1H0A92H0A93H0A94H0A95H0A96H0A97H0A98H0A9 9H0A109H0A110H0A111H0A120H0A121H0A122H0A 123H0A124H0A125H0A126H0A127H0A128H0A129H 0A213 HAppendix: Forms Index by Program (10/09)DBH FormsCOMC omplianceCOM014_EMedical Care Authorization for MinorCOM014_SMedical Care Authorization for Minor-SpanishCOM015_EConsent for Sound & Photographic RecordingsCOM016_EConsent To Record And/Or Photograph And Auth. For Use Or Disclosure EngCOM016_SConsent To Record And/Or Photograph And Auth For Use Or Disclosure-SpanCOM018_EAdvance Directive Notice (Client)COM018_SAdvance Directive Notice (Client)-SpanishCOM019 Delegation of TX ConsentCOM020 Conflict of Interest DisclosureCOM021_EAccess to Medical Records RequestCOM021_SAccess to Medical Records Request - SpanishCOM022_EResponse to Request to Access Medical Records COM022_SResponse to Request to Access Medical Records - SpanishCOM023_ERequest to Amend Protected Health Information (PHI)COM023_SRequest to Amend Protected Health Information (PHI) - SpanishCOM024_EResponse to Request to Amend Protected Health Information (PHI)COM024_SResponse to Request to Amend Protected Health Information (PHI)

8 - SpanishCOM025 Internal Tracking of Request to Access Medical RecordsCOM026_ERelease of Info: Patient's Right of Access to His/Her Own Medical Record-EnglishCOM026_SRelease of Info: Patient's Right of Access to His/Her Own Medical Record - SpanishCOM027 Oath of ConfidentialityCOM028_EAdvance Health Care Directive BrochureCOM028_SAdvance Health Care Directive - (Spanish) Brochure0A100H0A101H0A102H0A104H0A105H0A 106H0A107H0A108H0A112H0A113H0A114H0A115H 0A116H0A117H0A118H0A119H0A130H0A131H0A21 8H0A219H0A220H0A221H0A222 HAppendix: Forms Index by Program (10/09)COM028_SAdvance Health Care Directive (Spanish) BrochureCUL Cultural CompetencyCUL002 Translation RequestCUL003 Outside Vendor Services Request FormCUL004 Outside Vendor Cost ReportCUL005 Initial Contact LogCUL006 Interpretation Service RequestCUL009 Contract Language Services LogHRHuman ResourcesHR001 Position/Justification FormHR002 Waiver Request Cover LetterHR003 Pre-Lic MFT/MSW Stmt of Awareness of Need to Obtain Licensure for Continued EmploymentHR004 Overtime Autorization FormHR005 Unpaid Leave Due to No Proof of License or RegistrationHR006 Pre-Lic/Out-of-State Licensed Ready Psychologists Stmt of Awareness to obtain LicensureHR007 Dress and Grooming Acknowledgement FormHR008 DBH Intra Department Transfer (IDT)

9 FormHR009 Borrowed Position RequisitionHR010 Property Return ChecklistHR011 Exit Interview FormHR012 Employee Information Checklist0A100H0A101H0A102H0A104H0A105H0 A106H0A107H0A108H0A112H0A113H0A114H0A115 H0A116H0A117H0A118H0A119H0A130H0A131H0A1 32H0A133H0A134H0A135H0A136H0A137H0A138H0 A139H0A140H0A141H0A142H0A143H0A144H0A145 H0A146H0A147H0A218H0A219H0A220H0A221H0A2 22H0A223H0A224 HAppendix: Forms Index by Program (10/09)DBH FormsHRHuman ResourcesHR013 DBH New Hire Welcome LetterHR014 Tuberculosis Screening Confirmation FormHR015 Volunteer Services Program Request FormITInformation TechnologyIT002 Information Technology Systems Development Service RequestMDSM edical ServicesMDS001 Quarterly Physician's Cabinet InspectionMDS002_EMedication Consent FormMDS002_SMedication Consent form -SpanishMDS003 Verbal/Telephone Consent for Administration of Psychotropic Medication FormMDS004 letter to Parent-Legal guardian Juvenile Detention Template 1 MDS005 letter requesting Psychotropic Medication Template 2 MDS006 Alert Sheet for AllergiesMDS007 Outpatient Medication RecordMDS008 Medication Visit (ID Note)

10 MDS009 Medication Only Cases LogMH12 Mental Health Professional Licensing Waiver RequestPRPatients' RightsPR001 Patients' Rights Office Grievance Appeal FormQM Quality ManagementQM001 Chart Audit ToolQM045 Mode of Service/Procedure Code Change FormQM046 State Pre-Audit Chart Review Audit Tool0A148H0A149H0A150H0A151H0A152H0A153H 0A154H0A155H0A156H0A157H0A158H0A159H0A16 0H0A161H0A162H0A163H0A214H0A215H0A217 HAppendix: Forms Index by Program (10/09)QM047_EChange of Provider Request FormQM047_SChange of Provider Request FormQM048_ERequest for Second OpinionQM048_SRequest for Second OpinionQM049 Mental Health and Alcohol and Drug Services Agency EvaluationQM050_EGrievance FormQM050_SGrievance FormQM051_EAppeal FormQM051_SAppeal FormQM052 Quality Assurance Review of Unexpected DeathsQM053 Unusual Occurance/Incident ReportQM054 Clinic Supervisor Chart AuditsQM055 Program Manager Chart AuditQM056 Quality Assurance Audit At Annual PointQM057 Medication Monitoring