Forms

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

Authorization Services  

    The following forms are utilized by Alameda County Mental Health Plan Provider Network only.

• Request For Extended Service (RES) 
• Request for Concurrent Review (RCR) 
• 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

• John George Pavilion

JGP Insurance Plan Verification and Authorization Form
JGP 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    (PDF) / AOD   (PDF) ) - 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
• Letter To ACBHCS Contracted Providers
• Revised Procedure Procedure Code Table - January 2013

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)