Forms

Access / CCF / Clinical_Templates / Clinician's Gateway / DATAR / Intensive Care Coordination - Intensive Home Based Services / Insurance Verification / Information Systems Services Requests / InSyst / Med Consent Forms / NOABD / Office of Compliance Services / Prop 36 Tracking / SUD / TAY / TBS / Wraparound Child FSP

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

Access

Outpatient Services Referral Forms:
Child/Youth FSP WRAPAROUND Program Referral Form
Transitional Age Youth Mental Health Referral Form
Transitional Age Youth Mental Health Fillable Referral Form
Referral Form For Adult Outpatient Mental Health Services

HealthPAC
HealthPAC Eligibility and Referral Procedures for SMHS
HealthPAC Primary Care to Behavioral Health Referral and Initial Risk Assessment Form
Patient Health Summary Form

Prior Consultation
ACBHCS Request for Prior Consultation
ACBHCS Beneficiary Registration for Prior Consultation

Screening for Specialty Mental Health Services (Moderate-Severe Criteria)
Adult BH Screening Form
Adult BH Screening Form (fillable)
Child 6-17 BH Screening Form
Child 6-17 BH Screening Form (fillable)
Child 0-5 BH Screening Form
Child 0-5 BH Screening Form (fillable)
Medical Necessity for Specialty Mental Health Services
Screening Tool and Referral Instructions for ACBHCS Providers
Screening Tool Training FAQ’s
Bi-Directional Medi-Cal Mental Health Level of Care Transition Form
Bi-Directional Medi-Cal Mental Health Level of Care Transition Form - fillable

Primary Care Providers
Referral Procedure for Primary Care Providers (PCP)
Fax Cover Sheet for PCP Referrals for Specialty Mental Health Services (fillable)
Fax Cover Sheet for PCP Referrals for Specialty Mental Health Services

CCF

Clinician's Gateway

The following PDF version of these request forms are no longer available on the ACBH Providers web site:

Request to Change Clinician’s Gateway Treatment Plan
Request to Delete Clinician's Gateway Note
Staff List for CG Data Forms
Staff Authorization Request Form

The Help Desk will no longer accept requests that are either faxed or emailed. 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.
Clinician's Gateway User Manual – Admin. (Clinical Managers and Support Staff)
Clinician's Gateway User Manual – Clinician
Clinician's Gateway Training Manuals and Videos
CBO/FSP - Data Collection Agreement
Electronic Signature Agreement
Usage and Confidentiality Agreement
New CBO/FSP Readiness Review

Clinical Templates

DATAR

Web Portal/E-Forms page

Network Access

Intensive Care Coordination (ICC) - Intensive Home Based Services (IHBS)

Insurance Verification

SUD Insurance Plan Verification and Authorization Form
SUD Insurance Payment Notification Form

MHS Insurance Plan Verification and Authorization Form
MHS Insurance Payment Notification Form

John George Pavilion

JGP Insurance Plan Verification and Authorization Form
JGP Insurance Payment Notification Form

Medicare Provider Enrollment

Medicare Enrollment Notification Form – New Applications
Medicare Enrollment Notification Form – Existing Enrollments

Information Systems Services Requests

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

InSyst

SUD and CalOMS Client Data Collection Forms

	AB109 Source of Referral memo		PDF
	Episode Opening Living Situation Definitions		PDF (rev. 03/17)
	Client Registration - (WI)		PDF (rev. 03/21)
	Client Episode Opening - (WI)		PDF (rev. 04/19)
	Client Episode Opening - (NI)		PDF (rev. 07/17)
	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)
	Episode Annual Update - (WI)		PDF (rev. 04/17)
	Episode Annual Update - (NI)		PDF (rev. 04/17)
	CalOMS Top Twenty Errors		PDF
	CalOMS Tx State Clinical Review Guide		PDF (rev. 01/14)
	CalOMS Tx State Data Correction Guide		PDF (rev. 04/19)
	CalOMS Discharge Codes		PDF
	Insyst Table of Codes		PDF (rev. 03/21)

MHS Client Data Collection (CSI) Forms
Forms available with � No Instructions (NI) or With Instructions (WI)
Example:
Client Episode Opening - (WI)
Client Episode Opening - (NI)

	Client Registration - (WI)		PDF (rev. 03/21)
	Episode Opening - (WI)		PDF (rev. 10/18)
	Episode Opening - (NI)		PDF (rev. 10/18)
	Episode Update - (WI)		PDF (rev. 10/18)
	Episode Update - (NI)		PDF (rev. 10/18)
	Episode Closing - (WI)		PDF (rev. 10/18)
	Episode Closing - (NI)		PDF (rev. 10/18)
	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. 03/21)

MHS (CSI) TIMELINESS REPORTING DATA COLLECTION FORMS
Forms available with � No Instructions (NI) or With Instructions (WI)

	CSI Timeliness Data Collection (FINAL RULE) - (WI)		PDF (rev. 04/22)
	CSI Timeliness Data Collection (FINAL RULE) - (NI)		PDF (rev. 04/22)

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 ACBH 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

English

Chinese Traditional

Chinese Simplified

Farsi

Korean

Spanish

Tagalog

Vietnamese

Office of Compliance Services

Smartsheet Privacy Incident Report Form

Prop 36 Tracking

Authorization Request Form - to setup a User ID and Password for the Prop 36 Tracking System

SUD

Treatment Forms

ALOC Re-Assessment
Continuing Services Justification Recommendation Only
Continuing Services Justification
Discharge Plan
Discharge Summary
Drug Testing - Administrative Form
Initial Medical Necessity
SUD Brief Engagement
SUD Intake & Assessment
Release of Information Forms:

General RoI - New! 11/19 - use this RoI to release SUD client information to others within the SUD Provider Network. Every client must sign this release.
ROI Tracker Log Form - use this ROI Tracking Log for every ROI form that is signed by the client. The Tracker Log is maintained in the client’s medical record/file. Each time client information is released it must be logged.

Other:

Transition Age Youth (TAY) Mental Health Services Referral

TAY Referral Form