Attestation of Claim (PDF: 102 kB)

Avatar Correction Form (PDF: 44 kB)

Client Change of Status MHS 133 (07-15) (MS Word: 85 kB)

Provider Problem Resolution & Payment Appeal Form (PDF: 70 kB)

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)

State of California Department of Health Care Services Drug Medi-Cal Contract FY 20-23(PDF: 2.2 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)

State of California Department of Health Care Services Performance Contract FY 18-21 (MHSA, MHBG, etc.) (PDF: 1.5 MB)

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)

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)

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 Mental Health Provider Credentialing Procedure (PDF: 93 kB)

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

Mental Health Cost Report Fiscal Year 2020/21
CBO Cost Report Instructions(PDF: 330 kB)
Cost Report Checklist and Certification(PDF: 125 kB)
CBO Cost Report(MS Excel: 42 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 (MS Word: 86 kB)

Substance Use Disorder Invoice (Excel: 14 kB)

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 (MS Word: 47 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: 51 kB)

Supplemental Daily Patch Rate Agreement (PDF: 156 kB)

Board & Care/Long Term Care Census and Invoice Template (MS Excel: 18 kB)

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)