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CMS Plan and Fiscal Guidelines Forms and Templates for FY 06/07

This web page provides local Children's Medical Services (CMS) programs with digital files of most forms and templates found in the CMS Plan and Fiscal Guidelines Manual. These files are meant to facilitate the preparation of the local CMS plan and budget. Please refer to your manual for more detailed instructions on the use of these materials. 

Section 2: Plan Submission Instructions

Section 3: Scope of Work

Section 4: Data Forms 

Section 5: Inter/Intra-Agency Agreements (IAA) and Memoranda of Understanding (MOU) 

Section 6: Budget Instructions

Section 8: Expenditure Invoices and Equipment Management 

 

Section 2: Plan Submission Instructions

Document Name

Page Reference

CMS Plan and Budget Required Documents Checklist (Word) 2-7
Agency Information Sheet (Word) 2-9
Certification Statement - CHDP (Word) 2-10
Certification Statement - CCS (Word) 2-11
CCS Incumbent List (Word) 2-12
CHDP Incumbent List (Word) 2-13
HCPCFC Incumbent List (Word) 2-14
Memoranda of Understanding/Interagency Agreements List (Word) 2-15

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Section 3: Scope of Work 

Document Name

Page Reference

Performance Measure Profile (Word) 3-13
Performance Measure 1 (Word) 3-14, 3-15
Performance Measure 2 (Optional, Word) 3-16
Performance Measure 3 (Word) 3-17
Performance Measure 4 (Word) 3-18, 3 19
Performance Measure 5 (Word) 3-20, 3-21
Performance Measure 6 (Word) 3-22-3-23
Performance Measure 7 (Optional, Word) 3-24

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Section 4: Data Forms 

Document Name

Page Reference

Examples of Children Helped Through CMS (Word) 4-5
CCS Caseload Summary Sheet (Word) 4-9
CHDP Program Case Management Data (Word) 4-14
Quarterly Report of Medi-Cal Recipients Requesting CHDP Services (Word)  Section 10-103

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Section 5: Inter/Intra-Agency Agreements (IAA) and Memoranda of Understanding (MOU) 

Document Name

Page Reference

County/City CHDP Program Model Interagency Agreement (Word) 5-10 thru 5-24
MOU Between CCS and Healthy Families Program Plan (PDF Print Only) 5-4 thru 5-6
Delineation of Responsibility for CMS Branch, Regional Offices, and Dependent Counties as they Relate to Healthy Families MOU (PDF Print Only) 5-7 thru 5-9
Model HCPCFC MOU  (Word) 5-25 thru 5-28

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Section 6: Budget Instructions 

Document Name

Page Reference

CCS Administrative Budget Worksheet (Excel) 6-98, 6-99
CCS Worksheet Healthy Families (Excel)  6-105
CCS Administrative Budget Summary (Excel) 6-106
CCS Administrative Budget Revision Summary (Excel)  6-134
CCS Administrative Budget Revision Worksheet (Excel) 6-136, 6-137
Medical Therapy Program Claims Preparation Budget (Excel) 6-112
County/City Capital Expense Justification Form (Word) 6-16
County/City Other Expense Justification Form (Word) 6-17
CHDP Administrative Budget Worksheet County/City Match (Excel) 6-55, 6-56
CHDP Administrative Budget Summary County/City Match (Excel) 6-60
CHDP Administrative Budget Revision Summary County/City Match (Excel) 6-122
CHDP Administrative Budget Revision Summary No County/City Match (Excel) 6-118
CHDP Staffing Factors Fiscal Year 2004-05 Worksheet For Full-Time Equivalent (FTE) Calculations (Word) 6-29 thru 6-34
CHDP Administrative Budget Worksheet No County/City Match (Excel) 6-43, 6-44
CHDP Administrative Budget Summary No County/City Match (Excel) 6-49
HCPCFC Administrative Budget Worksheet (Excel) 6-77
HCPCFC Administrative Budget Summary (Excel) 6-80
HCPCFC Administrative Budget Revision Summary (Excel) 6-129
Foster Care Administrative Budget County/City Match (Excel) 6-66
Foster Care Administrative Budget County/City Match Summary (Excel) 6-69
Foster Care Administrative Budget Revision Summary County/City Match (Excel) 6-126

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Section 8: Expenditure Invoices and Equipment Management 

Document Name

Page Reference

CHDP Quarterly Administrative Expenditure Invoice (No County/City Match) (Excel) 8-11
CHDP Quarterly Administrative Expenditure Invoice (County/City Match) (Excel) 8-12
CCS Quarterly Administrative Expenditure Invoice (Excel)  8-32, 8-33
CCS Quarterly MTP Claims Preparation Expenditure Invoice (Excel)  8-69
CCS Quarterly Administrative Expenditure Invoice Supplemental Part A (Excel) 8-47, 8-48
CCS Quarterly Administrative Expenditure Invoice Supplemental Part B (Excel) 8-62, 8-63
Equipment Purchased with DHS Funds (HAS 1203) (Word)  8-86
Inventory/Disposition of DHS-Funded Equipment (HAS 1204) (Word)   8-87
Property Survey Report (STD 152) (PDF Fillable)   8-88
Instructions and Invoice Forms – Diagnostic, Treatment, and Therapy Expenditure Reporting (PDF Print Only) 8-70 thru 8-78
Invoice Forms – Diagnostic, Treatment, and Therapy Expenditure Reporting (Excel)  8-79 thru 8-83
Administrative Expenditure Invoices for the HCPCFC Administrative Budget and the CHDP Program Foster Care Administrative Budget (County/City Match) (PDF) CHDP Program Letter 03-32
HCPCFC Quarterly Administrative Expenditure Invoice (Excel) 8-15
CHDP Foster Care Quarterly Administrative Expenditure Invoice (Excel) 8-20

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Last modified on: 8/13/2008 8:31 AM