Placer County Network Provider Forms
Form Number and 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) Updated 08/05/2004
- 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 303KB) Updated 1/28/2013
- Care 015a - Completed with the Care 15, contains CSI data and cultural services (pdf 76KB)
- Care 020 - English version Appeal/Grievance Form used for both clients and providers to file a complaint (pdf 15KB) Updated 09/28/2012
- Care 020sp - Spanish version Appeal/Grievance Form used for both clients and providers to file a complaint (pdf 14KB) Updated 09/28/2012
- 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 - Child/Youth Biopsychosocial Assessment (This form is to be downloaded and used as a Template) (msword 556KB) Updated 07/18/2012 (REV. 06/08/2012)
- 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) Updated 10/16/2012
- Beneficiary Protection Spanish - Required Provider Posting Materials for Beneficiary Protection in Spanish (zip 423KB) Updated 10/16/2012
- 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) Updated 1/28/2013
- 2012 Provider Manual (DRAFT) - 2012 Provider Manual (DRAFT) (pdf 662KB) (revised 06/28/12)