Forms and Materials for Behavioral Health Contractors

Forms and other materials for use by organizations that contract with Behavioral Health.

For All Contractors

• Attestation of Claim (PDF: 102 kB)
• Avatar Correction Form (PDF: 44 kB)
• Client Change of Status MHS 133 (07-15) (PDF: 207 kB)
• Provider Problem Resolution & Payment Appeal Form (PDF: 70 kB)
• Staff Number Request Form (MH)
• Staff Number Request Form (SUD)
• Provider Credentialing Procedure 
• Client Grievances: Form Completion, Processing, and Reporting (Presentation)
• Client Grievances: Form Completion, Processing, and Reporting (PowerPoint)

Privacy and Security Incident Forms

• Contractor Privacy and Security Incident Report Form (PDF: 1.13 MB)
• Contractor Risk Assessment Form (PDF: 574 kB)

California Department of Health Care Services Contracts

• State of California Department of Health Care Services Contract FY 17-22 (PDF: 3.3 MB)
• Mental Health - Privacy and Information Security Provisions (PDF: 562 kB)
• Substance Abuse Treatment Block (SABG) – Privacy and Information Security Provisions (PDF: 433 kB)
• Substance Use Disorder - Privacy and Information Security Provisions (PDF: 1.6 MB)
• MHSA, SAMHSA, PATH, and Laura’s Law – Privacy and Information Security Provisions (PDF: 1.6 MB)
• Alcohol and/or Other Program Certification Standards (California Department of Health Care Services) (PDF: 311 kB)

Presentations

• Behavioral Health Contractor Forum Presentation November 27, 2018 (PDF: 248 kB)

Contractor Forum Materials

• Sonoma County Department of Health Services Contracting Process (PDF: 78 kB)
• Behavioral Health Staff Contact List for Contract Providers (PDF: 104 kB)
• Behavioral Health Contractor Forum Feedback (PDF: 192 kB)

For Medi-Cal Contractors Only

• Client Episode Admission - Electronic MHS 149 (05-17) (PDF: 318 kB)
  Legend (MS Word: 186 kB)
• Client Episode Discharge - Electronic MHS 150 (05-17) (PDF: 186 kB)
  Legend (MS Word: 26 kB)
• Client Service Information (CSI) Annual Update MHS 111 (03-17) (MS Word: 22 kB)
  Legend (PDF: 318 kB)
• Documentation and Scope of Practice Guidelines (PDF: 191 kB)
• Provider Self-Authorizer Requirements (MS Word: 125 kB)
• Exhibit A - Medi-Cal Contracts FY 14-15 (MS Word: 60 kB)
• Exhibit A - Medi-Cal Scope of Work FY 14-15 Additional Goals Form (MS Word: 39 kB)
• Location of Service Definitions (PDF: 129 kB)
• Client Rights & Grievance/Appeal Process and Form
  English | Spanish (PDF: 792 and 691 kB)
• Request for Change of Service Provider
  English | Spanish (PDF: 766 and 374 kB)
• MHS 112-1 NOABD Service Denial Notice
  English | Spanish (PDF: 856 and 879 kB)
• MHS 112-2 NOABD Payment Denial Notice
  English | Spanish (PDF: and 802 kB)
• MHS 112-3 NOABD Delivery System Notice
  English | Spanish (PDF: 859 kB and 778 kB)
• MHS 112-4 NOABD Modification Notice
  English | Spanish (PDF: 886 kB and 815 kB)
• MHS 112-5 NOABD Termination Notice
  English | Spanish(PDF: 838 and 882 kB)
• MHS 112-6 NOABD Authorization Delay Notice
  English | Spanish(PDF: 833 and 868 kB)
• MHS 112-7 NOABD Timely Access Notice
  English | Spanish(PDF: 825 and 860 kB)
• MHS 112-8 NOABD Financial Liability Notice
  English | Spanish (PDF: 834 kB and 791 kB) 
• MHS 112-9 NOABD Treatment Request Notice
  English (PDF: 768 kB)
• MHS 168 Beneficiary Request for Service Authorization
  English (PDF: 260 kB)
• Medi-Cal Informing Materials
• Medi-Cal Location Lockouts MHS 151 (04-15) (MS Word: 29 kB)
• Medi-Cal Outcomes Quarterly Report (MS Word: 37 kB)
  Email to BHquarterlyreports@sonoma-county.org
• Mental Health Cost Report Fiscal Year 2022/23
  CBO Cost Report Instructions (PDF: 1.1 MB)
  CBO Report Checklist and Certification
  CBO Cost Report (MS Excel: 45 kB)
  CBO Cost Report PPP Loan Check (PDF: 157 kB)
• Mental Health Services Invoice and Service Log/Directions/Example and Staff List (MS Excel: 64 kB)
• Payor Financial Information (PFI) MHS 107 118 (02-04)
  English | Spanish (MS Word: 76 kB)
• Residential Facility Invoice and Census and Staff List (MS Excel: 25 kB)
• Staff Number Request Form (PDF: 374 kB)
• Medi-Cal Mental Health Provider Credentialing Procedure (PDF: 93 kB)

For MHSA Contractors Only

• Media Guide for MHSA Contractors (PDF: 245 kB)
• MHSA Invoice Templates (MS Excel: 14 kB)
• MHSA Quarterly Report Template (MS Excel: 36 kB)
  Email to BHquarterlyreports@sonoma-county.org
• MHSA Quarterly Report "Narrative Only" Template (PDF: 840 kB)
  Email to BHquarterlyreports@sonoma-county.org
• MHSA Quarterly Report "Narrative Only" Instructions (PDF: 116 kB)
• Client Rights & Grievance/Appeal Process and Form
  English | Spanish (PDF: 774 kB)

For Board & Care/Long Term Care Contractors Only

• Supplemental Daily Patch Rate Agreement (PDF: 156 kB)
• Board & Care/Long Term Care Census and Invoice Template (MS Excel: 25 kB)

For Substance Use Disorders Contractors Only

• Substance Use Disorder Services Invoice (PDF: 1.8 MB)
• Substance Use Disorder Direct Services and Operating Cost Invoice (PDF: 1.9 MB)

For Whole Person Care Contractors Only

• Whole Person Care Health Center Invoice Template FY 20-21 (MS Excel: 29 kB)
• Whole Person Care Peer Outreach Worker Invoice Template FY 20-21 (MS Excel: 32 kB)
• Whole Person Care Intensive Case Management Clients Medical Treatment Plan (PDF: 70 kB)
• County of Sonoma Multi-Disciplinary Team Client Release of Information Form (PDF: 142 kB)
• Whole Person Care Referral Form (PDF: 336 kB)

Resources