Provider Forms

Placer County Behavioral Health Managed Care Network

2011 Provider Manual (DRAFT) (pdf 662KB) (revised 07/21/11)

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Behavioral Health Managed Care Forms
Form Number	Description
Provider Initial Assessment Forms Bundle	Bundle of forms includes the CARE 010, CARE 011, CARE 015, CARE 015a, CARE 015e, CARE 024, CARE 036 and HIPAA 05 (zip 282KB)
Care 008	Unified Service Plan (pdf 40KB)
Care 008e	Unified Service Plan (This form is to be downloaded and used as a Template) (msword 236KB)
Care 009	Request for Authorization / Treatment Plan Report to be printed and filled in by hand (pdf 29KB) Updated 07/10/2009
Care 009e	Request for Authorization / Treatment Plan Report (This form is to be downloaded and used as a Template) (msword 254KB) Updated 07/10/2009
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 57KB)
Care 015e	Required Biopsychosocial Assessment (This form is to be downloaded and used as a Template) (msword 282KB)
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 15KB)
Care 020sp	Spanish version of the Care 020 (pdf 14KB)
Care 024	Contains required CSI data (pdf 78KB)
Care 036	Consent to treat a minor (pdf 13KB)
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) (msword 43KB) Updated 02/27/2009
Care 041ge	Systems of Care Group Progress Note (This form is to be downloaded and used as a Template) (msword 53KB) Updated 09/05/2008
Care 141e	Findings Report Child Biopsychosocial Assessment (This form is to be downloaded and used as a Template) (msword 556KB) Updated 04/09/2009

Care 441	Psychiatric Consultation Request Adult Medi-Cal Beneficiaries (This form is to be downloaded and used as a Template) (msword 37KB) Updated 11/18/2010
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 312KB)
Beneficiary Protection Spanish	Required Provider Posting Materials for Beneficiary Protection in Spanish (zip 423KB)
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)
Tax Forms	County of Placer required Tax Forms (pdf 114KB)


Home > Departments > Health and Human Services > Managed Care > Provider Forms	Thursday, May 24, 2012