Forms

Access / CCF / Clinical_Templates / Clinician's Gateway / DATAR / Intensive Care Coordination - Intensive Home Based Services / Information Systems Services Requests / Med Consent Forms / NOABD / Office of Compliance Services / Other Health Coverage (OHC) / Prop 36 Tracking / SUD / TAY / TBS / Wraparound Child FSP



ACBH MyApps Access (https://MyApplications.Microsoft.com) Use the link above and your Username/Password to log into the ACBH Network for access to the eForms. If you do not have a Username, you will need to complete the Network Access form and email it to the IS Department. Please download the file and save on it on your local computer for future use. Access Outpatient Services Referral Forms Child/Youth FSP WRAPAROUND Program Referral Form Transitional Age Youth Mental Health Referral Form Transitional Age Youth Mental Health Fillable Referral Form Referral Form For Adult Outpatient Mental Health Services HealthPAC HealthPAC Eligibility and Referral Procedures for SMHS HealthPAC Primary Care to Behavioral Health Referral and Initial Risk Assessment Form Patient Health Summary Form Prior Consultation ACBHCS Request for Prior Consultation ACBHCS Beneficiary Registration for Prior Consultation Screening for Specialty Mental Health Services (Moderate-Severe Criteria) Adult BH Screening Form Adult BH Screening Form (fillable) Child 6-17 BH Screening Form Child 6-17 BH Screening Form (fillable) Child 0-5 BH Screening Form Child 0-5 BH Screening Form (fillable) Medical Necessity for Specialty Mental Health Services Screening Tool and Referral Instructions for ACBHCS Providers Screening Tool Training FAQ’s Bi-Directional Medi-Cal Mental Health Level of Care Transition Form Bi-Directional Medi-Cal Mental Health Level of Care Transition Form - fillable Primary Care Providers Referral Procedure for Primary Care Providers (PCP) Fax Cover Sheet for PCP Referrals for Specialty Mental Health Services (fillable) Fax Cover Sheet for PCP Referrals for Specialty Mental Health Services Claims Correction Form (CCF) Claim Correction Form (CCF) Clinician's Gateway The following PDF version of these request forms are no longer available on the ACBH Providers web site: Request to Change Clinician’s Gateway Treatment Plan Request to Delete Clinician's Gateway Note Staff List for CG Data Forms Staff Authorization Request Form The Help Desk will no longer accept requests that are either faxed or emailed. Please submit request using the Web Portal/E-Forms page. If you do not have network access please fill out a Network Access form. If you have any questions, please call the Help Desk at 510-567-8181. Clinician's Gateway User Manual – Admin. (Clinical Managers and Support Staff) Clinician's Gateway User Manual – Clinician Clinician's Gateway Training Manuals and Videos CBO/FSP - Data Collection Agreement Electronic Signature Agreement Usage and Confidentiality Agreement New CBO/FSP Readiness Review Clinical Templates Adult's Services Children's Services DATAR The PDF version of the DATAR request forms are no longer available on the ACBH Providers web site. The Help Desk will no longer accept faxed or emailed DATAR forms. Please submit request using the Web Portal/E-Forms page. If you do not have network access please fill out a Network Access form. If you have any questions, please call the Help Desk at 510-567-8181. Intensive Care Coordination (ICC) - Intensive Home Based Services (IHBS) ICC Cover Sheet - English ICC Cover Sheet - Spanish ICC Referral - English ICC Referral - Spanish ICC-IHBS CFT Care Plan Coversheet - English ICC-IHBS CFT Care Plan Coversheet - Spanish IHBS Cover Letter - English IHBS Cover Letter - Spanish IHBS Referral - English IHBS Referral - Spanish ICC-IHBS CFT Care Plan & Meeting Minutes - English ICC-IHBS CFT Care Plan & Meeting Minutes - Spanish Information Systems Services Requests Network Access - Use this form to request access to the ACBH network for completing an e-form request Provider Attestation Instructions - Use these instructions for accessing the ACBH Network and completing the Provider Attestation form Med Consent Forms English Chinese Traditional Chinese Simplified Farsi Korean Spanish Tagalog Vietnamese Office of Compliance Services Smartsheet Privacy Incident Report Form Other Health Coverage (OHC) Prop 36 Tracking Authorization Request Form - to setup a User ID and Password for the Prop 36 Tracking System SUD Treatment Forms Other: Informing Materials Client Health Questionnaire and Initial Screening Questions (DHCS 5103) Transition Age Youth (TAY) Mental Health Services Referral TAY Referral Form TBS TBS Referral Form Description and Referral Process - English TBS Referral Form Description and Referral Process - Spanish TBS Brochure TBS Coordination of Care Manual TBS Request for Authorization 1st Authorization for TBS Services Authorization for Additional TBS Services TBS Documentation Manual Authorization for extended TBS Services Request To Terminate Services Wraparound Child FSP Child/Youth FSP WRAPAROUND Program Information Sheet Child/Youth FSP WRAPAROUND Program Information Sheet - Spanish Child/Youth FSP WRAPAROUND Program Referral Form PDF Child/Youth FSP WRAPAROUND Program Referral Form Word