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
DHCS 5267 (10/18): Provider Information Management System (PIMS) County Approver Certification & Vendor Appointment Form

DHCS Application Portal Approval Forms

DHCS 7000 (09/19): County Approver Certification Form – SDMC-Mental Health
DHCS 7204 (09/19): County Approver Certification Form – SDMC-Alcohol and Drug Programs

DHCS 7201 (09/19) County Approver Certification Form – Cost and Financial Report Systems

DHCS 7202 (09/19) 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 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
DHCS 1819 Mental Health Services Act (MHSA) Prudent Reserve Assessment/Reassessment
DHCS 1820 Annual MHSA Revenue and Expenditure Report and Adjustment Worksheet County Certification
DHCS 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 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 1739 (07/13): 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 (10/19): 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 3007 PERSONAL BACKGROUND HISTORY STATEMENT
DHCS 3085 CRIMINAL BACKGROUND CHECK: CHARACTER REFERENCE
DHCS 3131 (10/19) Application for Mental Health Program Approval Short-Term Residential Therapeutic Programs (STRTP)

Last modified date: 10/17/2019 9:42 AM