Daim ntawv kho mob hlwb​​ 

Rov qab mus rau Mental Health Licensing and Certification​​ 

Medi-Cal Manual Claim Forms​​  

• MC 1982 A: Cov Kev Pabcuam Kev Mob Siab Tshwj Xeeb Medi-Cal Daim Ntawv Pov Thawj rau Tsoom Fwv Teb Chaws Them Nyiaj Rov Qab (Hloov Kho 04/2025)
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• MC 1982 B: Medi-Cal Tshwj Xeeb Kev Pabcuam Kev Puas Siab Puas Ntsws Kev Pabcuam Rau Peb Hlis Rau Kev Them Nyiaj Rov Qab - Tus Nqi Them Nqi:​​ 
• MC 1982B-1: SMHS Kev Thov Ua Ntej 9/30/2019 (88% MCHIP)​​ 
• MC 1982B-2: SMHS Kev Txais Los Ntawm 10/1/2019 txog 12/31/2019 (76.5% MCHIP)​​ 
• MC 1982B-3A: SMHS Kev Txais Los Ntawm 1/2020 txog 2/2020 (COVID - 80.84% MCHIP)​​ 
• MC 1982B-3B: SMHS Kev Txais Los Ntawm 3/1/2020 txog 3/31/2020 (COVID – 80.84% MCHIP)​​ 
• MC 1982B-4: Kev thov tom qab 3/31/2020 (COVID – 80.84%, 30% OA)​​ 
• MC 1982B-5: Kev thov tom qab 10/1/2020 (COVID 69.34%, 30% OA)​​ 
• MC 1982B-6: Kev thov tom qab 7/1/2021 (COVID 69.34%, 15% OA)​​ 
• MC 1982 C: SD/MC Daim Ntawv Thov Txhua hli rau Kev Them Nyiaj Rov Qab - Kev Pov Hwm Zoo/Kev Siv Tshuaj Xyuas (QA/UR) Tus Nqi​​ 
• MC 1982 D: SD/MC Peb Hlis Thov Kev Them Nyiaj Rov Qab - Medi-Cal Kev Tswj Xyuas Kev Ua Haujlwm (MAA)​​ 
• MC 1982 G: SD/MC Quarterly Claim for Reimbursement - Medi-Cal Administration Activities (MAA)​​ 

BHIS Daim Ntawv Pov Thawj​​ 

• 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. 08/2025): DCR County Approver Certification and Vendor Appointment Form​​ 
  
• DHCS 5267 (12/2019): Cov Txheej Txheem Tswj Xyuas Cov Ntaub Ntawv (PIMS) Lub Nroog Pom Zoo & Daim Ntawv Teev Npe Muag Khoom​​ 

DHCS Daim Ntawv Thov Kev Pom Zoo Portal​​ 

• 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 – Cov Nqi thiab Kev Qhia Txog Nyiaj Txiag​​ 
• DHCS 7202 (09/2019) Lub Nroog Pom Zoo Daim Ntawv Pov Thawj - 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​​ 
  

Daim ntawv pov thawj kev puas hlwb​​ 

• DHCS 1800 (MH 300): Electroconvulsive Treatment (ECT), Daim Ntawv Pom Zoo Pom Zoo​​ 
  
• DHCS 1800 SP: Electroconvulsive Treatment (ECT), Daim Ntawv Pom Zoo Pom Zoo (Spanish)​​ 
• DHCS 1801 (MH 302):​​  Daim ntawv thov txog li 72-teev Kev Ntsuam Xyuas, Kev Ntsuam Xyuas, thiab Kev cuam tshuam txog kev kub ntxhov lossis kev tso chaw rau kev ntsuam xyuas thiab kev kho mob​​ 
• DHCS 1801 SP: Daim ntawv thov txog li 72-teev Kev Ntsuam Xyuas, Kev Ntsuam Xyuas, thiab Kev cuam tshuam txog kev kub ntxhov lossis qhov chaw rau kev ntsuam xyuas thiab kev kho mob (Spanish)​​ 
  
• DHCS 1802 (MH 303): Involuntary Patient Advisment​​ 
  
• DHCS 1802 SP: Involuntary Patient Advisement (Spanish)​​ 
  
• DHCS 1803 (MH 306): Tus Neeg Mob Txoj Cai Tsis Pom Zoo - Txhua hli Talley​​ 
  
• DHCS 1804 (MH 307): Tsis kam lees txoj cai / cais tawm & txwv tsis pub - Txhua hli​​ 
  
• DHCS 1805 (MH 308): Tsis kam lees txoj cai / cais tawm & txwv tsis pub - Peb Hlis​​ 
  
• DHCS 1806 (MH 309): Convulsive Treatments Administered - Daim Ntawv Qhia Peb Hlis (siv DHCS 1011)​​ 
• DHCS 1807 (MH 560): Kev tso cai tso tawm cov ntaub ntawv tiv thaiv kev noj qab haus huv thiab cov ntaub ntawv tsis pub lwm tus paub​​ 
• DHCS 1807 SP: Kev tso cai tso tawm cov ntaub ntawv tiv thaiv kev noj qab haus huv thiab cov ntaub ntawv tsis pub lwm tus paub (Spanish)​​ 
  
• DHCS 1808 (MH 1760):​​  Daim ntawv ceeb toom ntawm Certification for Intensive Treatment Pursuant to Section 5250 (14 DaysIntensive Treatment) los yog 5270.15 (Ntxiv 30 Hnub Intensive Treatment for Grave Disability) ntawm Welfare and Institutions Code​​ 
  
• DHCS 1808 SP: Daim Ntawv Ceeb Toom Txog Kev Kho Mob hnyav Raws li Tshooj 5250 (14 DaysIntensive Treatment) lossis 5270.15 (Ntxiv 30 Hnub Intensive Treatment for Grave Disability) ntawm Welfare and Institutions Code (Spanish)​​ 
  
• DHCS 1809 (MH 1761): Daim Ntawv Ceeb Toom Txog Kev Pom Zoo rau Kev Kho Mob Ntxiv 14 Hnub​​ 
• DHCS 1810: Cov Khoom Muag ntawm Lub Nroog 5150 Cov Chaw Tsim Nyog​​ 
• DHCS 1811 (MH 5671): Kev tso cai tso tawm cov ntaub ntawv tus neeg mob​​ 
• DHCS 1812 (MH 5756): Daim ntawv thov tuaj yeem nkag rau cov neeg xiam oob khab​​ 
• DHCS 1819 Mental Health Services Act (MHSA) Prudent Reserve Assessment/Reassessment​​ 
  
• DHCS 1820 MHSA Daim Ntawv Qhia Txog Nyiaj Tau Los thiab Kev Siv Nyiaj Txhua Xyoo thiab Kev Hloov Daim Ntawv Pov Thawj Hauv Nroog​​ 
• DHCS 1821 MHSA: Kev Kho Kom Zoo Rau Cov Nyiaj Tau Los thiab Cov Nqi Them Nqi Ua Haujlwm​​ 
• DHCS 1822A Ib Xyoo MHSA Daim Ntawv Qhia Nyiaj Tau Los thiab Kev Siv Nyiaj Txhua Xyoo thiab Cov Lus Qhia​​ 

Lwm daim ntawv kho mob puas hlwb​​ 

• DHCS 1011 (11/2022): Daim Ntawv Qhia Peb Hlis rau Kev Kho Mob thiab Kev Kho Mob Psychosurgery​​ 
  
• DHCS 1012 (12/2022): Daim Ntawv Flexibility Program rau Mental Health Rehabilitation Center​​ 
  
• DHCS 1013 (12/2022): Daim Ntawv Flexibility Program rau Psychiatric Health Facility​​ 
  
• DHCS 1735 Medi-Cal (M/C) Certification Transmittal (09/2014)​​ 
• DHCS 1736 Daim Ntawv Pov Thawj Ua Haujlwm Hauv Nroog thiab Ua Haujlwm (09/2014)​​ 
• DHCS 1737 Daim Ntawv Tshawb Fawb Txog Tus Kheej Hauv Nroog (09/2014)​​ 
  
• DHCS 1739 (08/2024): 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): Daim ntawv tso cai - Mental Health Rehabilitation Center (MHRC)​​ 
  
• DHCS 1816 Daim Ntawv Pov Thawj Txog Nyiaj Txiag (MHRC)​​ 
• DHCS 1814 (08/2022): Daim Ntawv Tso Cai - Psychiatric Health Facility (PHF)​​ 
• DHCS 1817 Daim Ntawv Pom Zoo Txog Tus Neeg Mob Nyiaj (PHF)​​ 
  
• DHCS 1815 (1/2025): Daim Ntawv Tso Cai Tshwj Xeeb ntawm Cov Kev Pabcuam Sab Nraud​​ 
  
• DHCS 1818 (07/2014) Daim Ntawv Ceeb Toom Kev Pom Zoo Kev Hloov Pauv​​ 
• DHCS 3007 PERSONAL BACKGROUND HISTORY STATEMENT​​ 
• DHCS 3085 CRIMINAL BACKGROUND Kuaj: CEEB TOOM​​ 
• DHCS 6030 Daim Ntawv Thov rau Daim Ntawv Tso Cai Ua Ntej rau Kev Kho Mob Psychiatric Residential Residential Treatment Facility (PRTF)​​ 
  
• DHCS 6031 Psychiatric Residential Treatment Facility Affidavit About Resident Money (PRTF)​​ 
  
• DHCS 6032 Daim Ntawv Pom Zoo Txhua Xyoo ntawm Kev Ua Raws Li Ntu G ntawm Tshooj 483 ntawm Title 42 ntawm Txoj Cai Tswjfwm Ntiag Tug​​ 
  
• DHCS 6033 Daim Ntawv Thov Kev Rov Ntxiv Daim Ntawv Tso Cai Rau Kev Kho Mob Psychiatric Residential Treatment Facility (PRTF)​​