- Home
- Portal
- County Homepage
- Government
- Health & Human Services
- Behavioral Health
- Organizational Provider Resources
Organizational Provider Resources
Forms
- Clients - Adults and Children
- Clients - Children Only
- Informing Materials
- NOABDs
- Practitioner Enrollment
- QI
- Referral, Authorization, Claim
- 1006 ROI
- 1006S ROI Spanish
- 1013 Client Information Form Annual Update
- 1014 Client Plan
- 1028 Health History Questionnaire
- 1042 Outpatient Medication Advisement
- 1061 HCBH Adult Referral Form
- 1096 Assessment
- 1127 Client Information Form
- 1173 Mental Status Exam
- 1195 Informed Consent for Outpatient Services
- 1196 Informing Materials Packet-Client Acknowledgement
- 1232 Continuity of Care Request
- 4017 Text Messaging Communications Consent
- 1004.25 CANS-SB_Humboldt 2.0
- 1061C HCBH CFS Referral Form
- 1068 TBS Assessment
- 1172 Medical Necessity Criteria for TBS
- 1210 CFT Meeting Summary
- 1211 IHBS Assessment
- 1212 IHBS Authorization and Medical Necessity
- 1213 IHBS Referral Coversheet
- 1227 Pediatric Symptom Checklist
- 1238 Youth Behavioral Health Assessment
- Access Brochure-Info about HCBH (tan paper)
- Access Brochure-Info about HCBH Spanish (tan paper)
- Advance Directive Brochure (yellow paper)
- Advance Directive Brochure Spanish (yellow paper)
- BH Patients' Rights Poster
- BH Patients' Rights Poster Spanish
- Client Plan Availability (bilingual)
- Client Problem Resolution Guide (large print)
- Client Problem Resolution Guide (pink paper)
- Client Problem Resolution Guide poster
- Client Problem Resolution Guide poster Spanish
- Client Problem Resolution Guide Spanish (pink paper)
- Client Problem Resolution Request Form (large print)
- Client Problem Resolution Request Form (pink paper)
- Client Problem Resolution Request Form Spanish (pink paper)
- Did you know (bilingual)
- Emergency Medical Services
- Emergency Medical Services Spanish
- Health Care Practitioner Info (bilingual)
- MHP_Beneficiary_Handbook
- MHP_Beneficiary_Handbook_large print
- MHP_Beneficiary_Handbook_Spanish
- Notice of Privacy Practices-DHHS 55
- Notice of Privacy Practices-DHHS 56 (Spanish)
- Notice to Consumers MDs (bilingual)
- Provider List Sign (bilingual)
- QI-79 Brochure and Posting Requirements rev 8-7-20
- Rates Explanation and Service Rates Schedule
- Rates Explanation and Service Rates Schedule Spanish
- Request for Change of Provider (blue paper)
- Request for Change of Provider (blue paper, large print)
- Request for Change of Provider Spanish (blue paper)
- Request for Second Opinion (green paper)
- Request for Second Opinion (green paper, large print)
- Request for Second Opinion Spanish (green paper)
- Your Health Information Privacy Rights Poster
- 1045 NOABD Authorization Delay
- 1045 NOABD Delivery System
- 1045 NOABD Denial
- 1045 NOABD Financial Liability
- 1045 NOABD Grievance or Appeal Timely Resolution
- 1045 NOABD Modification
- 1045 NOABD Payment Denial
- 1045 NOABD Termination
- 1045 NOABD Timely Access
- 1045s NOABD - Authorization Delay Spanish
- 1045s NOABD - Delivery System Spanish
- 1045s NOABD - Denial Spanish
- 1045s NOABD - Financial Liability Spanish
- 1045s NOABD - Grievance or Appeal Timely Resolution Spanish
- 1045s NOABD - Modification Spanish
- 1045s NOABD - Payment Denial Spanish
- 1045s NOABD - Termination Spanish
- 1045s NOABD - Timely Access Spanish
- QI-108 NOABD Your Rights Attachment
- QI-109 Beneficiary Nondiscrimination Notice
- QI-110 Language Assistance Taglines
- 1127 Client Information Form
- 1127b Contract Provider Diagnosis Form
- 1127b Contract Provider Diagnosis Form 10-8-20
- 1127b Contract Provider Diagnosis Form 2020
- 1127c Contract Provider Face Sheet
- 1242 ARTS-CRTS Authorization
- 1243 Contract Provider SMHS Referral
- CBH Org Provider Authorization Paperwork Matrix
- CBH Org Provider Referral Paperwork Matrix
- QI-49 MCO Disallowance
Policies & Procedures
- 0100.300 Suspected Child Abuse and Neglect Reporting
- 0100.301 Suspected Dependent Adult and Elder Abuse Reporting
- 0100.302 Duty to Protect
- 0100.604 Access to Interpreters and Competent Providers
- 0100.610 Long Term Care Beneficiary
- 0406.101 Access to Services
- 0704.0460 Client Problem Resolution Process
- 0704.341 Medi-Cal Site Certifications-Recertifications
- 0704.370 QM Chart Review
- 0704.390 ASOC Outpatient Services Authorization of Day Treatment Services
- 0704.420 Beneficiary Rights
- 0704.500 Notice of Adverse Benefit Determination
- 0704.540 Provider Problem Resolution Process
- 0704.660 OOC Hospitalizations
- 0704.871 Access To Services For Clients Out Of County
- 0704.873 Auth of Out-of-Plan Services For Foster Care, Aid to Adoptions and Kin-GAP Children
- 0704.875 Continuity of Care
- 0704.877 Distribution Of Informing Materials
- 0704.878 Provider Selection, Certification and Re-Certification
- 0704.879 Required Documents by Contract Providers
- 0704.880 Out of County Provider Documentation Monitoring
- 0704.881 Notice to Clients of Provider Contract Termination
- 0704.882 Accessible Client Materials Policy
- 0704.980 Staff Worksheet
- 1001.005 CANS-Humboldt
- 1001.100 Request for Access to Services CFS
- 1001.200 Authorization and Referral Process for In County IHBS
- 1001.800 Client Service Authorization and Exit Criteria
- 0100.599 Pre-Assessment Support to Access Outpatient Services
- 0704.670 ARTS Authorization
- 0704.671 CRTS Authorization
- 0704.680 Outpatient SMHS Authorization