Mental Health Forms
Medi-Cal Manual Claim Forms
MC 1982 A: SD/MC Quarterly Claim for Reimbursement - Treatment Cost
MC 1982 B: SD/MC Quarterly Claim for Reimbursement - Administrative Cost.pdf
MC 1982 B: SD/MC Quarterly Claim for Reimbursement - Administrative Cost.xls
MC 1982 C: SD/MC Monthly Claim for Reimbursement - Quality Assurance/Utilization Review (QA/UR) Cost
MC 1982 D: SD/MC Quarterly Claim for Reimbursement - Medi-Cal Administrative Activities (MAA)
MC 1982 D: SD/MC Quarterly Claim for Reimbursement - Medi-Cal Administrative Activities (MAA)
ITWS Certification Forms
MC 5254: ITWS Business Partner Certification
MC 5257: ITWS DHCS Employee Certification
MC 5258: ITWS Vendor Certification
MC 5272: ITWS County Certification
The forms below have been transitioned to the Dept of Social Services and may be found by clicking on this link.
MH 12: Mental Health Professional Licensing Waiver Request
MH 300: Electroconvulsive (ECT), Informed Consent Form
MH 302: Application for 72 Hour Detention for Evaluation and Treatment
MH 303: Involuntary Patient Advisement
MH 306: Patient Rights Denial - Monthly Talley
MH 307: Denial of Rights/Seclusion & Restraint - Monthly
MH 308: Denial of Rights/Seclusion & Restraint - Quarterly
MH 309: Convulsive Treatments Administered - Quarterly Report
MH 560: Authorization for Release of Protected Health Information and Confidential Information
MH 1760: Notice of Certification
MH 1761: Notice of Certification for Additional 14 Days Intensive Treatment
MH 5150: Annual Blank 5150 Inventory Form
MH 5388: Vocational Services Discharge Summary
MH 5671: Authorization for Release of Patient Information
MH 5756: Voluntary Admission Application for Mentally Disabled Person
Other Mental Health Forms