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Sample County and Contract Forms and Resources

Sample County and Contract Forms and Resources. Reasons for Recoupment Included Diagnosis List NOA-A & Back English Spanish Vietnamese Farsi Korean Arabic Consumer Rights Poster English Spanish Vietnamese Farsi Korean JV220 Application (typically for SSA or Probation Staff to complete)

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Sample County and Contract Forms and Resources

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  1. Sample County and Contract Forms and Resources • Reasons for Recoupment • Included Diagnosis List • NOA-A & Back EnglishSpanishVietnameseFarsiKoreanArabic • Consumer Rights Poster EnglishSpanishVietnameseFarsiKorean • JV220 Application (typically for SSA or Probation Staff to complete) • JV220A • JV220B • BHS Medi-Cal Provider Info

  2. Sample Contract Forms and Resources Only • Assessment Summary (v7.0) • Six-Month Update or update page (v7.0) • Annual Update (v7.0) • Treatment Plan for Non-Assessment Services (Interim Care Plan - ICP) • Care Plan • MD Med Monitoring Contract (Brief) • MD Med Monitoring Contract (Long) • MD ED/Progress Note Contract • CYBH ED/Progress Note Contract • Contract Psychiatrist Hard Copy • Contract Regional Hard Copy • Contract Rehab Hard Copy • Contract STRTP Hard Copy • Contract TAY Hard Copy

  3. Sample Contract Assessments & Care Plan • Regional Contract Sample Assessment & CP • Rehab Contract Sample Assessment & CP • STRTP Contract Sample Assessment & CP • TAY Contract Sample Assessment & CP • Sample Psychological Testing Report • Sample Annual Update & CP • Sample Interim Care Plan (ICP)

  4. Sample Progress Notes Contract Progress Notes (Paper) STRTP Progress Notes Assessment Individual Therapy Collateral Therapy Crisis Psychotherapy Family/Collateral Rehab IHBS ICC Child Family Team Meeting • Case Management • Assessment • Individual Therapy • Family Therapy • Group Therapy • Crisis Intervention • Crisis Psychotherapy • Individual Rehab • Family Rehab • IHBS • ICC

  5. Webpage Links for NPT Revised 2018 Trainings Slide 20 Reason for Recoupment Link Slide 23 Included Diagnosis List Slide 52 (Go to Sample Contract Assessments & Care Plan Above) Slide 86 (Go to Sample Progress Notes Above) Slide 114 Group Note Slide 154 Informed Consent for Treatment Slide 154 Guide to Medi-Cal Mental Health Services and List of Providers Slide 154 Notice of Privacy Practices (NPP) – MHP and Provider version Slide 159 (Go to Sample County and Contract Forms and Resources above) Slide 160 English Beneficiary Rights Poster Slide 162 Feb 2016 Info Notice (DHCS) Slide 162Updated Pathways to Well-Being (Katie A)/ICC & Intensive Services assessment form Slide 162Info Notice 17-055 ICC and IHBS Lockout Removal Slide 174 CYBH Coding and Documentation Manual Slide 186 Revocation Form: Revocation of ATD Slide 186 Instructions: Instructions for Revocation of ATD Slide 187 ATD Form Slide 187 Instructions and Training Slide 187 Policies and Procedures Slide 188 02.05.01 Notice of Privacy Practices Slide 188 04.05.03 Use and Disclosure of PHI – General Slide 188 05.01.07 Missing/Lost Charts Slide 188 05.01.08 Transport of Clinical Records

  6. Webpage Links for NPT Revised 2018 Trainings Continue Slide 188 *05.05.02 Tracking Disclosures of PHI *Tracking Disclosure Form Slide 188 05.05.03 Accounting for Disclosures of PHI Slide 190 HIPAA P&Ps: https://ocgov.sharepoint.com/Collab/SvcAreas/GRC/HIPAA/Pages/OC-HIPAA-Policies.aspx Slide 191-192 Sanctions for Privacy & Security Violations III-1.05 Slide 200 http://www.healthleadersmedia.com/physician-leaders/mn-health-clinic-fires-32-hipaa-violations Slide 201 Voter Registration Info: http://intranet.ochca.com/bhs Slide 201 http://elections.cdn.sos.ca.gov/nvra/sb35/sb35-workshop-january2013.pdf Slide 201 NPP 02.05.01 Slide 201 Car Seat Safety Law Slide 201 Advance Directive (For SUD and Mental Health Programs) Slide 201 Trafficking & Violence Protection Act Slide 201 Elder/Dependent Adult Abuse Reporting Slide 201 Intake Advisement Checklist Slide 212 County Code of Conduct Ver. 7 Slide 215 BHS P&Ps: http://ochealthinfo.com/bhs/pnp Slide 217 P&P 05.01.03 Documentation of Services Slide 217 P&P 07.01.01 Fraud and Abuse Slide 217 P&P 07.01.02 Billing Compliance Slide 232 NPI Website

  7. Webpage Links for NPT Revised 2018 Trainings Contract Regional Slide 234 Sample Interim Care Plan (ICP) Slide 235 Regional Contract Sample Assessment & CP Slide 236 http://www.ceasar-boston.org/CRAFFT/screenCRAFFT.php Slide 236 http://tfcbt.musc.edu/ Slide 237 (Go to Sample Progress Notes – Contract Progress Note – Paper above) Contract Rehab Slide 234 Sample Interim Care Plan (ICP) Slide 235 Rehab Contract Sample Assessment & CP Slide 237 (Go to Sample Progress Notes – Contract Progress Note – Paper above) Contract STRTP Slide 234 Sample Interim Care Plan (ICP) Slide 235 STRTP Contract Sample Assessment & CP Slide 238 (Go to Sample Progress Notes – STRTP Progress Notes above) Contract TAY Slide 238 Sample Interim Care Plan (ICP) Slide 238 TAY Contract Sample Assessment & CP Slide 238 (Go to Sample Progress Notes – Contract Progress Note – Paper above)

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