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

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

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Forms & Documents By Category

   

Contract Renewal Documents  

  • Standard Exhibit A Attachments
    • Exhibit A-1: Mental Health (MH) Additional Terms and Conditions
    • Exhibit A-2: MH QA Addendum for Medi-Cal Treatment Programs
    • Exhibit A-1: Substance Use Disorder (SUD) Additional Terms and Conditions
    • Exhibit A-2: SUD Additional Provisions for Perinatal Programs
  • Standard Exhibit B: Payment Terms and Conditions
  • Standard Exhibit C: Insurance Requirements
    • Exhibit C-2C: Insurance Requirements for For-Profit Health Care Services
    • Exhibit C-4: Insurance Requirements for Non-Profit Health Care Services
    • Exhibit C-13A: Insurance Requirements for Medical Services Providers
  • Other Exhibits
    • Exhibit D: Audit Requirements
    • Exhibit E: Business Associate Provisions (HIPAA)
    • Exhibit F: Debarment and Suspension Certification
    • Exhibit G: Lobbying Restrictions and Disclosure Certification (Contracts with >$100,000 in federal funding)
    • Exhibit H: Qualified Service Organization Agreement (SUD Contracts Only)
    • Exhibit O: The Iran Contract Act (ICA) of 2010
  • Reference Only

Mental Health  

Unaccompanied Youth – Alameda County: Letter to Providers

Housing/Homeless Criteria and Definition of Terms
EveryOne Home Alameda County Continuum of Care (CoC) Council Prioritization for Permanent Supportive Housing Opportunities

School Based Behavioral Health Programs Shift of Funds Request Psychological Testing Family Engagement and Group Services Reminder
 

MHP Provider Network Forms  

  • Provider Update Form (Form No. 50-02)– Use this form to updated BHCS of changes such as:
    • your location/address
    • email, phone, or fax
    • name
    • a change to status with any licensing/oversight board that may impact your ability to provide, claim or be reimbursed for specialty mental health services
  • Voluntary Disenrollment Form (Form No. 50-03) – Use this form to voluntarily dis-enroll from the MHP Provider Network
  • FAQs

Substance Use Disorder  


Coming soon

 

Standard  



Organizational and/or Program Changes Forms

Other Standard Forms