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CMS Plan and Fiscal Guidelines Forms and Templates for FY 07/08

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

Other Forms   

 

Section 2: Plan Submission Instructions

Document Name

Page Reference

CMS Plan and Budget Required Documents Checklist  (Word) 2-6
Agency Information Sheet (Word) 2-8
Certification Statement - CHDP (Word) 2-9
Certification Statement - CCS (Word) 2-10
CCS Incumbent List (Word) 2-11
CHDP Incumbent List (Word) 2-12
HCPCFC Incumbent List (Word) 2-13
Memoranda of Understanding/Interagency Agreements List (Word) 2-14

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Section 3: Scope of Work

Document Name

Page Reference

CHDP - Care Coordination (Word) 3-13
CHDP - New Provider Orientation (Word) 3-14
CHDP - Provider Recertification (Word) 3-15
CHDP - Desktop Review (Word) 3-16
CHDP - Childhood Overweight (Word) 3-17, 3-18, 3-19
HCPCFC - Care Coordination (Word) 3-20
HCPCFC - Health and Dental Exams (Word)  3-21
CHDP - School Entry Exams (Optional) (Word) 3-22
CCS - Medical Home (Word) 3-25
CCS - Determination of CCS Program Eligibility (Word) 3-26
CCS - Special Care Center: Part A (Word) 3-27
CCS - Special Care Center: Part B (Word) 3-28
CCS - Transition Planning (Word) 3-30
CCS - Family Participation (Word) 3-31, 3-32

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Section 4: Data Forms

Document Name

Page Reference

CCS Caseload Summary Sheet (Word) 4-9
CHDP Program Case Management Data (Word) 4-11

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Section 5: Memoranda of understanding (mou) and Inter/Intra-Agency Agreements (IAA)   

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 Responsibilities 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)  6-129
CCS Administrative Budget Revision Worksheet (Excel) 6-131, 6-132
County/City Capital Expenses Justification Form (Word) 6-16
County/City Other Expenses 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) 6-117
CHDP Administrative Budget Revision Summary No County/City Match (Excel) 6-113
CHDP Guidelines Staffing Factors Fiscal Year 2008-09 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) 6-124
CHDP Foster Care Administrative Budget County/City Match (Excel) 6-66
CHDP Foster Care Administrative Budget County/City Match Summary (Excel) 6-69
CHDP Foster Care Administrative Budget Revision Summary County/City Match (Excel) 6-121

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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) 8-12
CHDP Quarterly Administrative Expenditure Invoice (County/City Match) (Excel)  8-13
CCS Quarterly Administrative Expenditure Invoice (Excel)  8-33, 8-34
CCS Quarterly Administrative Expenditure Invoice Supplemental Part A  (Excel) 8-48, 8-49
CCS Quarterly Administrative Expenditure Invoice Supplemental Part B (Excel) 8-63
Equipment Purchased with DHS Funds (HAS 1203) (Word) 8-92
Inventory/Disposition of DHS-Funded Equipment (HAS 1204) (Word) 8-93
Property Survey Report (STD 152) (PDF Fill-able)  8-94
Instructions and Invoice Forms – Diagnostic, Treatment, and Therapy Expenditure Reporting (PDF Print Only)  8-67 thru 8-80
Invoice Forms – Diagnostic, Treatment, and Therapy Expenditure Reporting (Excel)  8-81 thru 8-84
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)  8-17
CHDP Foster Care Quarterly Administrative Expenditure Invoice (Excel)  8-21
Invoice Form Healthy Families Diagnostic, Treatment, Therapy Expenditures (Excel) 8-89
CMSB A-2 Annual Inventory (Excel) 8-96

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Other Forms 

Document Name

Page Reference

Certificate of Appropriations - CCS Diagnostic, Treatment & Therapy (Word) None
Re-Certification Form for CCS Diagnostic, Treatment & Therapy (Word) None
Certificate of County Appropriations - CCS Administrative Budget (Word) None

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