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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, CARE 141 e and HIPAA 05 (489KB)
  • Care 008 - Unified Service Plan (40KB)
  • Care 008e - Unified Service Plan (This form is to be downloaded and used as a Template) (236KB) Updated 08/05/2004
  • Care 009 - Request for Authorization / Treatment Plan Report to be printed and filled in by hand (29KB) Updated 07/10/2009
  • Care 009e- Request for Authorization / Treatment Plan Report (This form is to be downloaded and used as a Template) (254KB) Updated 07/10/2009
  • Care 010 - Data used to track Child treatment outcomes or treatment planning (65KB)
  • Care 011 - Data used to track Adult treatment outcomes or treatment planning (66KB)
  • Care 015 - Required Biopsychosocial Assessment (57KB)
  • Care 015e - Required Biopsychosocial Assessment (This form is to be downloaded and used as a Template) (303KB) Updated 4/22/2014
  • Care 015a - Completed with the Care 15, contains CSI data and cultural services (76KB)
  • Care 020 - English version Appeal/Grievance Form used for both clients and providers to file a complaint (15KB) Updated 12/11/2013
  • Care 020sp - Spanish version Appeal/Grievance Form used for both clients and providers to file a complaint (14KB) Updated 12/18/2013
  • Care 024 - Contains required CSI data (78KB)
  • Care 036 - Consent to treat a minor (13KB)
  • Care 041 - Systems of Care Progress Note (13KB)
  • Care 041e - Systems of Care Progress Note (This form is to be downloaded and used as a Template) (43KB) Updated 02/27/2009
  • Care 041ge - Systems of Care Group Progress Note (This form is to be downloaded and used as a Template) (53KB) Updated 09/05/2008
  • Care 141e - Child/Youth Biopsychosocial Assessment (This form is to be downloaded and used as a Template) (556KB) Updated 8/28/2014 (REV. 8/20/2013)
  • Care 441 - Psychiatric Consultation Request Adult Medi-Cal Beneficiaries (This form is to be downloaded and used as a Template) (37KB) Updated 11/18/2010
  • HIPAA 05 - Required when communicating with others regarding a client (410KB)
  • CPT/HCPCS CODES - Schedule of Contracted Rates Using Standardized CPT/HCPCS Codes (15KB)
  • CMS-1500 - This is only an example, the areas in yellow should be filled in on the CMS-1500 (141KB)
  • Beneficiary Protection English - Required Provider Posting Materials for Beneficiary Protection in English (250KB) Updated 12/11/2013
  • Beneficiary Protection Spanish - Required Provider Posting Materials for Beneficiary Protection in Spanish (304KB) Updated 12/18/2013
  • 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 (1.5MB)
  • Tax Forms - County of Placer required Tax Forms (114KB) Updated 1/28/2013
  • 2014 Provider Manual - 2014 Provider Manual (1.2MB) (revised 01/01/14)
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