Forms and other materials for use by organizations that contract with Behavioral Health.
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)
Contractor Privacy and Security Incident Report Form (PDF: 1.13 MB)
Contractor Risk Assessment Form (PDF: 574 kB)
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)
Behavioral Health Contractor Forum Presentation November 27, 2018 (PDF: 248 kB)
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 Outcomes Quarterly Report FY 14-15 (MS Word: 37 kB) Email to BHquarterlyreports@sonoma-county.org
Mental Health Cost Report Fiscal Year 2019/20 CBO Cost Report Instructions(PDF: 373 kB)Cost Report Checklist and Certification(PDF: 125 kB)CBO Cost Report(MS Excel: 44 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)
Medi-Cal Mental Health Provider Credentialing Procedure (PDF: 93 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)
Behavioral Health Division
Health Services
2227 Capricorn Way
Suite 207
24-hour Access Line
(707) 565-6900(800) 870-8786
24-Hour Crisis Services
(707) 576-8181Crisis Stabilization Unit2225 Challenger Way, Santa Rosa
24-hour Suicide Prevention
(855) 587-6373