​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​Mental Health Forms

Back to Mental Health Licensing and Certification

Medi-Cal Manual Claim Forms 

• MC 1982 A: SD/MC Quarterly Claim for Reimbursement - Treatment Cost 
• MC 1982 B: Medi-Cal Specialty Mental Health Services Quarterly Claim for Reimbursement - Administrative Cost:
• MC 1982B-1: SMHS Claims Before 9/30/2019 (88% MCHIP)
• MC 1982B-2: SMHS Claims From 10/1/2019 to 12/31/2019 (76.5% MCHIP)
• MC 1982B-3A: SMHS Claims From 1/2020 to 2/2020 (COVID – 80.84% MCHIP)
• MC 1982B-3B: S​MHS Claims From 3/1/2020 to 3/31/2020 (COVID – 80.84%MCHIP)
• MC 1982B-4: Claims After 3/31/2020 (COVID – 80.84%, 30% OA)
• MC 1982B-5: Claims After 10/1/2020 (COVID 69.34%, 30% OA)
• MC 1982B-6: Claims After 7/1/2021 (COVID 69.34%, 15% OA)​​​​​​​​
• ​​​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 (Rev. 09/2021): CSI County Approver Certification & Vendor Appointment Form
• DHCS 5260 (09/2021): FAST County Approver Certification & Vendor Appointment Form
• DHCS 5262 (Rev. 09/2021): DCR County Approver Certification and Vendor Appointment Form
• DHCS 5267 (12/2019): Provider Information Management System (PIMS) County Approver Certification & Vendor Appointment Form

DHCS Application Portal Approval Forms

• DHCS 7000 (09/2019): County Approver Certification Form – SDMC-Mental Health
  
• DHCS 7204 (09/2019): County Approver Certification Form – SDMC-Alcohol and Drug Programs
• DHCS 7201 (09/2019) County Approver Certification Form – Cost and Financial Report Systems
• DHCS 7202 (09/2019) County Approve Certification Form – Consumer Perception Survey

ITWS Certification Forms 

• MC 5254: ITWS Business Partner Certification
• MC 5257: ITWS DHCS Employee Certification
• MC 5258: ITWS Vendor Certification
• MC 5273: 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 18​01 (MH 302): Application for up to 72-Hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment
• ​DHCS 1801 SP​: Application for up to 72-Hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment (Spanish)
  
• 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 Re​lease of Protected Health Information and Confidential Information (Spanish)
  
• DHCS 1808 (MH 1760): Notice of Certification for Intensive Treatment Pursuant to Section 5250 (14 DaysIntensive Treatment) or 5270.15 (Additional 30 Days Intensive Treatment for Grave Disability) of the Welfare and Institutions Code​
  
• DHCS 1808 SP: Notice of Certification for Intensive Treatment Pursuant to Section 5250 (14 DaysIntensive Treatment) or 5270.15 (Additional 30 Days Intensive Treatment for Grave Disability) of the Welfare and Institutions Code​ (Spanish​)​
  
• 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
• DHCS 1819 Mental Health Services Act (MHSA) Prudent Reserve Assessment/Reassessment
  
• DHCS 1820 Annual MHSA Revenue and Expenditure Report and Adjustment Worksheet County Certification
• DH​CS 1821 MHSA: Adjustments to Revenue and Expenditure Summary Worksheet
• DHCS 1822A Annual MHSA Annual Revenue and Expenditure Report Template and Instructions

Other Mental Health Forms

• DHCS 1011 (11/2022): Quarterly Report for Convulsive Treatment and Psychosurgery Administered
  
• DHCS 1012 (12/2022): Program Flexibility Form for Mental Health Rehabilitation Center
  
• DHCS 1013 (12/2022): Program Flexibility Form for Psychiatric Health Facility​
  
• 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 1739 (07/2013): Mental Health Professional Licensing Waiver Request
  
• DHCS 1740 (05/2020):Delegation of Approval TasShort-Term Residential Therapeutic Program​
• DHCS 1746 Director's Designee Information
• ​​DHCS 1813 (08/2022): Application for Licensure - Mental Health Rehabilitation Center (MHRC)
  
• DHCS 1816 Affidavit Regarding Client Money (MHRC)
• DHCS 1814 (08/2022): Application for Licensure - Psychiatric Health Facility (PHF)
• 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 3007 PERSONAL BACKGROUND HISTORY STATEMENT
• DHCS 3085 CRIMINAL BACKGROUND CHECK: CHARACTER REFERENCE