providing mental health &
substance abuse  services for
the people of Alameda County ...  
   

Click here to go to homepage!

2000 Embarcadero Cove, Suite 400, Oakland, CA  94606
Phone: (510) 567-8100    Driving Directions

   Advanced Search   

Forms

   

Please download the file and save on it on your local computer for future use.

Access  

Utilization Management Program (UM) (formerly Authorization Services)  

    The following forms are to be utilized by the Alameda County Mental Health Plan Provider Network effective July 1, 2016.

    Service Authorization Request for initial or continuing authorization for SB785 clients.


CCF  


Clinician's Gateway  


Clinical Templates  


DATAR  

    The PDF version of the DATAR request forms are no longer available on the BHCS Providers web site. The Help Desk will no longer accept faxed or emailed DATAR forms. Please submit request using the Web Portal/E-Forms page. If you do not have network access please fill out a Network Access form. If you have any questions, please call the Help Desk at 510-567-8181.

Insurance Verification  


Information Systems Services Requests  

  • Network Access - Use this form to request access to the BHCS network for completing an e-form request
  • Provider Attestation Instructions - Use these instructions for accessing the BHCS Network and completing the Provider Attestation form

InSyst  

  • SUD and CalOMS Client Data Collection Forms (effective 03/17)
    New forms available with – No Instructions (NI) or With Instructions (WI)

    Example:
    Client Registration - (WI)
    Client Registration - (NI)
  AB109 Source of Referral memo   PDF   
  Episode Opening Living Situation Definitions PDF   (rev. 03/17)
  Client Registration - (WI) PDF   (rev. 03/17)
  Client Registration - (NI) PDF   (rev. 04/17)
  Client Episode Opening - (WI) PDF   (rev. 07/17)
  Client Episode Opening - (NI) PDF   (rev. 07/17)
  Episode Annual Update - (WI) PDF   (rev. 04/17)
  Episode Annual Update - (NI) PDF   (rev. 04/17)
  Standard Discharge Closing - (WI) PDF   (rev. 03/17)
  Standard Discharge Closing - (NI) PDF   (rev. 04/17)
  Admin Discharge Closing - (WI) PDF   (rev. 03/17)
  Admin Discharge Closing - (NI) PDF   (rev. 04/17)
  CalOMS Discharge Codes - (NI) PDF  
  CalOMS Top Twenty Errors PPT
  CalOMS Error and Correction Guide PDF
  CalOMS Tx Data Collection Guide PDF
  • MHS Client Data Collection (CSI) Forms (effective 03/17)
    New forms available with – No Instructions (NI) or With Instructions (WI)

    Example:
    Client Registration - (WI)
    Client Registration - (NI)
  Client Registration - (WI)   PDF   (rev. 08/17)
  Client Registration - (NI)   PDF   (rev. 08/17)
  Episode Opening - (WI)   PDF   (rev. 03/17)
  Episode Opening - (NI)   PDF   (rev. 04/17)
  Episode Update - (WI)   PDF   (rev. 03/17)
  Episode Update - (NI)   PDF   (rev. 04/17)
  Episode Closing - (WI)   PDF   (rev. 03/17)
  Episode Closing - (NI)   PDF   (rev. 04/17)
  One Time Client Episode Update - (WI)
- CBO Only -
PDF   (rev. 03/17)
  Individual Staff Service - (WI)   PDF   (rev. 03/17)
  Individual Staff Service - (NI)   PDF   (rev. 04/17)
  CalWORKS Individual Staff Log   PDF   (rev. 10/09)
  Periodic Form - (WI)   PDF   (rev. 03/17)
  Periodic Form - (NI)   PDF   (rev. 04/17)
  Insyst Table of Codes   PDF   (rev. 07/17)

EFF: 07/01/17 - MHS ONLY - 3 NEW LANGUAGES HAD BEEN ADDED TO THE LANGUAGE MASTER TABLE

  • 6 = HINDI
  • 7 = PASHTO
  • 8 = PUNJABI

EFF: 03/22/2017 – INSYST Update for MHS and SUD Clients: InSyst Update V010

EFF: 7/1/09 – NEW SERVICE LOCATION CODE: 22-COURT

Service Entry Codes- code removed.
EFF: 7/21/06 – REMOVED SERVICE LOCATION CODE: 21-UNKNOWN
CODE 21-UNKNOWN IS NOT MEDI-CAL BILLABLE – ALL SERVICES BEGINNING JULY 2006.

  • Please read the following instructions before submitting a request for a Mental Health staff number:
    View instructions
    Staff Number(MHS / SUD) - Effective Monday, September 15, 2014, the PDF version of the Staff Number request forms are no longer available on the BHCS Providers web site. The Help Desk will no longer accept Staff Number requests that are either faxed or emailed. Please request all staff numbers using the Web Portal/E-Forms page. If you do not have network access please fill out a Network Access form. If you have any questions, please call the Help Desk at 510-567-8181.
  • Letter To ACBHCS Contracted Providers
  • Revised Procedure Procedure Code Table - January 2013

Med Consent Forms  


NOA Forms  


Prop 36 Tracking  


Quality Assurance/Clinical Quality Review Team  


SUD  

Treatment Forms
The sample treatment forms below are intended to assist SUD Providers in meeting required state and federal standards of care and to give guidance for clinical documentation. Theses forms provide a template that can be edited and personalize to fit service needs.

TAT  


TBS