Forms

Please download the file and save on it on your local computer for future use.

Authorization Services  

    The following forms are utilized by Level III Provider Network only.

• Request for Concurrent Review (RCR)
• Request for Extended Service Review (RES)
• Beneficiary Registration (Part I)
• Beneficiary Registration (Part II)
• Request for Prior Consultation
• Request for Extended CalWorks Services

Clinician's Gateway  

• Admin Support Servs & Clinical Managers Hands-on Introduction Training
• Clinical Hands-on Introduction Training
• CBO/FSP - Data Collection Agreement
• Electronic Signature Agreement
• New CBO/FSP Readiness Review
• Request to Change Clinician’s Gateway Treatment Plan
• Request to Delete Clinician's Gateway Note
• Staff Authorization Request Form
• Staff List for CG Data Forms
• Usage and Confidentiality Agreement

Clinical Templates  

• Adult's Services
• Children's Services

DATAR  

• User Request

Insurance Verification  

• AOD

AOD Insurance Plan Verification and Authorization Form
AOD Insurance Payment Notification Form

• MHS

MHS Insurance Plan Verification and Authorization Form
MHS Insurance Payment Notification Form

• Medicare Provider Enrollment

Medicare Enrollment Notification Form – New Applications
Medicare Enrollment Notification Form – Existing Enrollments

Information Systems Services Requests  

• Report Request - to create/modify reports or run existing reports
• Service Request - to make request on software, hardware, network communication and other computing needs

InSyst  

• AOD Client Data Collection Forms

• MHS Client Data Collection (CSI) Forms (effective 7/1/06)

Service Entry Codes – New Code ADDED.
EFF: 7/1/09 – NEW SERVICE LOCATION CODE: 22-COURT

Service Entry Codes- code removed.
EFF: 7/21/06 – REMOVED SERVICE LOCATION CODE: 21-UNKNOWN
CODE 21-UNKNOWN IS NOT MEDI-CAL BILLABLE – ALL SERVICES BEGINNING JULY 2006.

• Please read the following instructions before submitting a request for a Mental Health staff number:
  View instructions
  All forms submitted to the Help Desk must be typed; handwritten forms will be returned.
  Staff Number (MHS / AOD) - to acquire an InSyst staff number for clinical staff
  (NOTE: staff numbers will not be issued without NPI and Taxonomy code.  Please see http://bhcsproviders.acgov.org/providers/NPI/NPI.htm for more information.)
• User Authorization (MHS / AOD) - to setup InSyst username and access to InSyst database
• Disallowed Claim Systems (DCS) - to report services claimed in error.  Please read the instructions on how to report errors to BHCS.
• Beneficiary Registration For Prior Consultation
• Request for Prior Consultation
• Client Data Registration
• Client Data Update
• Merge Request Form - to merge duplicate INSYST client records
• Alcohol and Drug Void and Replace Form
• Mental Health Void and Replace Form

Prop 36 Tracking  

• Authorization Request Form - to setup a User ID and Password for the Prop 36 Tracking System

Quality Assurance/Clinical Quality Review Team  

Access QA forms and CQRT materials.

TBS  

• Initial Screening Criteria For TBS Eligibility (pdf)