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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.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 G: SD/MC Quarterly Claim for Reimbursement - Medi-Cal Administrative Activities (MAA)

BHIS Certification Forms

DHCS 5259 (06/16): CSI County Approver Certification & Vendor Appointment Form

DHCS 5262 (Rev. 07/17): DCR County Approver Certification and Vendor Appointment Form

DHCS 5260 (Rev. 06/18): FAST County Approver Certification & Vendor Appointment Form

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

Mental Health Certification Forms

DHCS 1800 (MH 300): Electroconvulsive Treatment (ECT), Informed Consent Form

DHCS 1800 SP: Electroconvulsive Treatment (ECT), Informed Consent Form (Spanish)

DHCS 1801 (MH 302): Application for Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment

DHCS 1802 (MH 303): Involuntary Patient Advisement

DHCS 1802 SP: Involuntary Patient Advisement (Spanish)

DHCS 1803 (MH 306): Patient Rights Denial - Monthly Talley

DHCS 1804 (MH 307): Denial of Rights/Seclusion & Restraint - Monthly

DHCS 1805 (MH 308): Denial of Rights/Seclusion & Restraint - Quarterly

DHCS 1806 (MH 309): Convulsive Treatments Administered - Quarterly Report (use DHCS 1011)

DHCS 1807 (MH 560): Authorization for Release of Protected Health Information and Confidential Information

DHCS 1807 SP: Authorization for Release of Protected Health Information and Confidential Information  (Spanish)

DHCS 1808 (MH 1760): Notice of Certification

DHCS 1809 (MH 1761): Notice of Certification for Additional 14 Days Intensive Treatment

DHCS 1810: Inventory of County 5150 Designated Facilities

DHCS 1811 (MH 5671): Authorization for Release of Patient Information

DHCS 1812 (MH 5756): Voluntary Admission Application for Mentally Disabled Person

Other Mental Health Forms

DHCS 1008 (02/13): Jail Services.pdf

DHCS 1009 (02/13): Conservatorships.pdf

DHCS 1010 (02/13): Involuntary Detentions.pdf

DHCS 1011 (02/13): Convulsive Treatments.pdf 

DHCS 1735 Medi-Cal (M/C) Certification Transmittal (09/2014)

DHCS 1736 County-Owned and Operated Certification Application (09/2014)

DHCS 1737 County-Owned and Operated Provider Self-Survey Form (09/2014)

DHCS 1738 (08/14): County Mental Health Plan (MHP) Attestation

DHCS 1739 (06/13): Mental Health Professional Licensing Waiver Request 

DHCS 1746 Director's Designee Information

MC 5400 (05/2013): Application for Certification of Special Treatment Program (STP) Services

DHCS 1734 (06/13): Application for Certification of Social Rehabilitation Program Services

DHCS 1813 (11/2013) / MH8001/95: Application for Licensure Mental Health Rehabilitation Center (MHRC) 

DHCS 1816 Affidavit Regarding Client Money (MHRC)

DHCS 1814 (11/2013): Application for Licensure Psychiatric Health Facility (PHF) and Program

DHCS 1817 Affidavit Regarding Patient Money (PHF)

DHCS 1815 (11/2013): Application for a Special Permit of Structured Outpatient Services (SOPS)

DHCS 1818 (07/2014) Criminal Record Approval Transfer Notification



DHCS 3131 (04/18) Application for Mental Health Program Approval Short-Term Residential Therapeutic Programs (STRTP)

Last modified on: 7/3/2018 4:53 PM