|
Behavioral Health Managed Care Forms |
| Form Number |
Description |
| Care 008 |
Unified Service Plan (PDF, 40KB) |
| Care 008e |
Unified Service Plan (This form is to be downloaded and used as a Template) (DOC, 236KB) |
| Care 009e |
Required when requesting additional services be authorized (This form is to be downloaded and used as a Template) (DOC, 300KB) |
| Care 010 |
Data used to track child treatment outcomes or treatment planning (PDF, 65KB) |
| Care 011 |
Data used to track adult treatment outcomes or treatment planning (PDF, 66KB) |
| Care 015 |
Required Biopsychosocial Assessment (PDF, 100KB) |
| Care 015e |
Required Biopsychosocial Assessment (This form is to be downloaded and used as a Template) (DOC, 318KB) |
| Care 015a |
Completed with the Care 15, contains CSI data and cultural services (PDF, 76KB) |
| Care 020 |
Used for both clients and providers to file a complaint (PDF, 10KB) |
| Care 020a |
Spanish version of the Care 20 (PDF, 57KB) |
| Care 024 |
Contains required CSI data (PDF, 78KB) |
| Care 036 |
Required when treating a minor (PDF, 36KB) |
| Care 041 |
Systems of Care Progress Note (PDF, 13KB) |
| Care 041e |
Systems of Care Progress Note (This form is to be downloaded and used as a Template) (DOC, 42KB) |
| HIPAA 05 |
Required when communicating with others regarding a client (PDF, 410KB) |
| CPT/HCPCS CODES |
Schedule of Contracted Rates Using Standardized CPT/HCPCS Codes (PDF, 15KB) |
| CMS-1500 |
This is only an example, the areas in yellow should be filled in on the CMS-1500 (PDF, 458KB) |
| Beneficiary Protection English |
Required Provider Posting Materials for Beneficiary Protection in English (ZIP, 257KB) |
| Beneficiary Protection Spanish |
Required Provider Posting Materials for Beneficiary Protection in Spanish (ZIP, 358KB) |
| DSM-IV-TR to ICD-9-CM Crosswalk |
DSM-IV-TR to ICD-9-CM Crosswalk, ICD-9-CM Fifth-Digit Descriptions and Criteria, and Global Assessment of Functioning (GAF) Scale (PDF, 1.5MB) |