dhs-bh-banner-500x100.png

Forms and Materials
for Behavioral Health Contractors

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

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: 115 kB)

NOABD Service Denial Notice
English |  Spanish (MS Word: 70 and 82 kB)

NOABD Payment Denial Notice
English |  Spanish (MS Word: 67 and 70 kB)

NOABD Delivery System Notice
English |  Spanish (MS Word: 64 and 64 kB)

NOABD Modification Notice
English |  Spanish (MS Word: 64 and 65 kB)

NOABD Termination Notice
English |  Spanish (MS Word: 63 and 65 kB)

NOABD Authorization Delay Notice
English |  Spanish (MS Word: 76 and 78 kB)

NOABD Timely Access Notice
English |  Spanish (MS Word: 60 and 63 kB)

Medi-Cal Informing Materials

Medi-Cal Location Lockouts MHS 151 (04-15) (MS Word: 29 kB)

Medi-Cal Outcomes Quarterly Report FY 14-15 (MS Word: 37 kB)
Email to BHquarterlyreports@sonoma-county.org

Mental Health 18-19 Cost Report and Service Code Crosswalk(MS Excel: 33 kB)

Mental Health Services Invoice and Service Log/Directions/Example and Staff List (MS Excel: 61 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 (MS Word: 86 kB)

Medi-Cal Mental Health Provider Credentialing Procedure (PDF: 93 kB)

State of California Department of Health Care Services Contract FY 13-18 (PDF: 6.5 MB)

State of California Department of Health Care Services Contract FY 17-22 (PDF: 3.3 MB)

For MHSA Contractors Only

For Board & Care/Long Term Care Contractors Only

Contact Information

Behavioral Health Division

Health Services

Contact us by Phone
Address

2227 Capricorn Way

Suite 207

Santa Rosa, CA 95407

Mental Health Hotlines

24-hour Access Line

(707) 565-6900
(800) 870-8786

24-Hour Crisis Services

(707) 576-8181
Crisis Stabilization Unit
2225 Challenger Way, Santa Rosa

24-hour Suicide Prevention

(855) 587-6373

Sign Up for Our MHSA Newsletter