CMSPFT0910

CMS Plan and Fiscal Guidelines Forms and Templates for FY 09/10

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.

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Section 2: Plan and Budget Submission Instructions

Section 3: Scope of Work and Performance Measures

Section 4: Data Forms

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

Section 6: Budget Instructions

Section 7: Expenditure Claims and Property Management

Section 2: Plan and budget submission instructions

Document Name	Page Reference
CMS Plan and Budget Requred 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

Section 3: Scope of work and performance measures

Document Name	Page Reference
CHDP Performance Measure 1 - Care Coordination (Word)	3-12
CHDP Performance Measure 2 - New Provider Orientation (Word)	3-13
CHDP Performance Measure 3 - Provider Recertification (Word)	3-14
CHDP Performance Measure 4 - Desktop Review (Word)	3-15
CHDP Performance Measure 5 - Childhood Overweight (Word)	3-16, 3-17, 3-18
CHDP Performance Measure 6 - School Entry Exams (Optional) (Word)	3-19
CHDP Report Form (Word)	3-20
HCPCFC Performance Measure 1 - Care Coordination (Word)	3-21
HCPCFC Performance Measure 2 - Health and Dental Exams (Word)	3-22
CCS Performance Measure 1 - Medical Home (Word)	3-24
CCS Performance Measure 2 - Determination of CCS Program Eligibility (Word)	3-25, 3-26
CCS Performance Measure 3 (A & B) - Special Care Center (Word)	3-27, 3-28
CCS Performance Measure 4 - Transition Planning (Word)	3-29, 3-30
CCS Performance Measure 5 - Family Participation (Word)	3-31
Reporting Form	3-32
Performance Measure Profile	3-33

Section 4: Data forms

Document Name	Page Reference
CCS Caseload Summary Form (Word)	4-7
CHDP Program Referral Data (Word)	4-11

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 (Word)	5-4 thru 5-6
Delineation of Responsibilities for CMS Branch, Regional Offices, and Dependent Counties as They Relate to Healthy Families MOU (Word)	5-7 thru 5-9
Model HCPCFC MOU (Word)	5-25 thru 5-28

Section 6: Budget instructions

Document Name	Page Reference
CCS Administrative Budget Worksheet (Excel)	6-96
CCS Administrative Budget Summary (Excel)	6-102
County/City Capital Expense Justification Form (Word)	6-14
County/City Other Expense Justification Form (Word)	6-15
CHDP Administrative Budget Worksheet County/City Match (Excel)	6-53
CHDP Administrative Budget Summary County/City Match (Excel)	6-58
CHDP Staffing Factors Fiscal Year 2009-10 Worksheet For Full-Time Equivalent (FTE) Calculations (Word)	6-27
CHDP Administrative Budget Worksheet No County/City Match (Excel)	6-41
CHDP Administrative Budget Summary No County/City Match (Excel)	6-47
HCPCFC Administrative Budget Worksheet (Excel)	6-75
HCPCFC Administrative Budget Summary (Excel)	6-78
Foster Care Administrative Budget County/City Match (Excel)	6-64
Foster Care Administrative Budget County/City Match Summary (Excel)	6-67

Section 7: Expenditure Claims and Property Management

Document Name	Page Reference
CHDP Quarterly Administrative Expenditure Invoice (County/City Match) (Excel)	7-12, 7-13
CHDP Quarterly Administrative Expenditure Invoice (No County/City Match) (Excel)	7-20, 7-27
CCS Administrative Expenditure Invoice (Excel)	7-48
CCS Administrative Expenditure Invoice - Supplemental (Part A) (Excel)	7-65
CCS Administrative Expenditure Invoice - Supplemental (Part B) (Excel)	7-81
CCS Administrative Medi-Cal Expenditure Invoice (County Match) (Excel)	7.53
CCS Claim for Reimbursement Diagnostic / Treatment / Therapy (Excel)	7-97 thru 7-100,7-102
CCS Healthy Families (HF) Quarterly Report Of Expenditures (Excel)	7-105
HCPCFC Quarterly Administrative Expenditure Invoice (Excel)	7-32
CHDP Foster Care Quarterly Administrative Expenditure Invoice (Excel)	7-36
CMSB A-2 Annual Inventory of State Furnished Equipment(Excel)	7-111