Forms

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

Access  

• HealthPAC
  HealthPAC Eligibility and Referral Procedures for SMHS
  HealthPAC Primary Care to Behavioral Health Referral and Initial Risk Assessment Form
  Patient Health Summary Form

 
• Psychological Testing
  ACBHCS Psychological Testing Protocol
  ACBHCS Psychological Testing Authorization Request (PTAR)

 
• 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

 

Utilization Management Program (UM) (formerly Authorization Services)  

    The following forms are to be utilized by the Alameda County Mental Health Plan Provider Network effective July 1, 2016.

• Request for Continued Service (RCS) – fillable online version
• Request for Continued Service (RCS) – printable version
• Provider Attestation – fillable online version)
• Provider Attestation – printable version
• Outpatient Network Specialty Mental Health Services - Package of Services

    Service Authorization Request for initial or continuing authorization for SB785 clients.

• Service Authorization Request

CCF  

• CCF Training
• CCF Training with Notes
• CCF FAQ
• Claim Correction Form (CCF)

Clinician's Gateway  

• The following PDF version of these request forms are no longer available on the BHCS 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
• 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 BHCS 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.

Insurance Verification  

• SUD

SUD Insurance Plan Verification and Authorization Form
SUD 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  

• Network Access - Use this form to request access to the BHCS network for completing an e-form request
• Provider Attestation Instructions - Use these instructions for accessing the BHCS Network and completing the Provider Attestation form

InSyst  

• SUD and CalOMS Client Data Collection Forms (effective 03/17)
  New forms available with – No Instructions (NI) or With Instructions (WI)
  
  Example:
  Client Registration - (WI)
  Client Registration - (NI)

• MHS Client Data Collection (CSI) Forms (effective 03/17)
  New forms available with – No Instructions (NI) or With Instructions (WI)
  
  Example:
  Client Registration - (WI)
  Client Registration - (NI)

EFF: 07/01/17 - MHS ONLY - 3 NEW LANGUAGES HAD BEEN ADDED TO THE LANGUAGE MASTER TABLE

• 6 = HINDI
• 7 = PASHTO
• 8 = PUNJABI