Fee for Service Providers

This page is utilized by Fee For Service MediCal Providers to obtain documentation related to participation on the MediCal panel and continued authorizations for treatment.

Applications

Name Description Date
* 0 Instructions and FAQs Credentialing and Contracting 6.29.18.docx
2018-07-11
* 1 Credentialing Application 6.29.18.docx
2018-07-11
* 2 Provider Clinical Application FFS Medi-Cal 06.29.18.docx
2018-07-11
* 3 FFS Clincal Speciality Addition App 06.29.18.docx
2018-07-10
* BHETA - Acessing an ELEARNING (pdf)
2018-01-16
* BHETA - How to Print Certificate (pdf)
2018-01-16
* BHETA Acct Creation Instructions (pdf)
2017-11-29
* Form W-9 (Rev. December 2014)
2017-11-02

Beneficiary Materials

Name Description Date
* Notice of Privacy Practices Acknowledgement Arabic 2014.docx
2018-05-25
* Notice of Privacy Practices Acknowledgement English 2014.docx
2018-05-25
* Notice of Privacy Practices Acknowledgement Spanish 2014.docx
2018-05-25
* Notice of Privacy Practices Acknowledgement Tagalog 2014.docx
2018-05-25
* Notice of Privacy Practices Acknowledgement Vietnamese 2014.docx
2018-05-25
* Advance Directive Arabic.pdf
2015-10-09
* Advance Directive English.pdf
2015-10-09
* Advance Directive Spanish.pdf
2015-10-09
* Advance Directive Tagalog.pdf
2015-10-09
* Advance Directive Vietnamese.pdf
2015-10-09
* FullGuide Arabic 2013.pdf
2016-10-12
* FullGuide Spanish 2013.pdf
2016-10-12
* FullGuide English.pdf
2016-10-12
* FullGuide Tagalog 2013.pdf
2016-06-28
* FullGuide Vietnamese 2013.pdf
2016-10-12
* GrievanceAndAppealPoster Arabic.pdf
2018-05-25
* GrievanceAndAppealPoster English.pdf
2018-05-25
* GrievanceAndAppealPoster Tagalog.pdf
2018-05-25
* GrievanceAndAppealPoster Vietnamese 04-2012.pdf
2018-05-25
* LimitedEnglishProficiencyPoster Arabic 03-17-05.pdf
2018-05-25
* LimitedEnglishProficiencyPoster English.pdf
2018-05-25
* LimitedEnglishProficiencyPoster Spanish.pdf
2018-05-25
* LimitedEnglishProficiencyPoster Vietnamese.pdf
2018-05-25
* NoticeofPrivacyPractices Arabic 12-16-14.pdf
2018-05-25
* NoticeofPrivacyPractices English 12-16-14.pdf
2018-05-25
* NoticeofPrivacyPractices Spanish 12-16-14.pdf
2018-05-25
* NoticeofPrivacyPractices Tagalog 12-16-14.pdf
2018-05-25
* NoticeofPrivacyPractices Vietnamese 12-16-14.pdf
2018-05-25
* Recovery Brochure English 8-5-13.pdf
2018-05-25
* Recovery Brochure Spanish 09-11rev.pdf
2018-05-25
* Grievance and Appeal Form-CCHEA Advocacy Spanish 1-15-16.pdf
2018-05-25
* Grievance and Appeal Form-JFS Advocacy English 1-15-16.pdf
2018-05-25
* Grievance and Appeal Form-JFS Advocacy Vietnamese 1-15-16.pdf
2018-05-25
* Grievance and Appeal Form-CCHEA Advocacy Tagalog 1-15-16.pdf
2018-05-25
* Grievance and Appeal Form-CCHEA Advocacy Arabic 1-15-16.pdf
2018-05-25
* Grievance and Appeal Form-CCHEA Advocacy English 1-15-16.pdf
2018-05-25
* Grievance and Appeal Form-CCHEA Advocacy Vietnamese 1-15-16.pdf
2018-05-25
* Grievance and Appeal Form-JFS Advocacy Tagalog 1-15-16.pdf
2018-05-25
* Grievance and Appeal Form-JFS Advocacy Spanish 1-15-16.pdf
2018-05-25
* Grievance and Appeal Form-JFS Advocacy Arabic 1-15-16.pdf
2018-05-25
* ACL Poster.pdf
2016-10-12
* Grievance-Appeal Brochure FINAL Rv 10 17 17 Vietnamese.pdf
2017-12-13
* Grievance-Appeal Brochure FINAL Rv 10 17 17 Tagalog.pdf
2017-12-13
* Grievance-Appeal Brochure FINAL Rv 10 17 17 Spanish.pdf
2017-12-13
* Grievance-Appeal Brochure FINAL Rv 10 17 17 Arabic.pdf
2017-12-13
* Grievance-Appeal Brochure FINAL Rv 10 17 17 English.pdf
2017-12-13
* Grievance and Appeal Form - CCHEA Advocacy 12 20 17 FARSI.docx
2017-12-22
* Grievance and Appeal Form - JFS Advocacy 12-20-17 FARSI.docx
2017-12-22
* LimitedEnglishProficiencyPoster Farsi2-1-18.pdf
2018-05-18
* FullGuide Farsi rev2018.pdf
2018-05-18

Communications

Forms

Name Description Date
* Advance Health Care Directives.pdf
2018-05-25
* Coordination of Care Release Form San Diego.doc
2015-10-09
* FINAL Coordination of Care Form Arabic.doc
2018-05-25
* FINAL Coordination of Care Form Arabic.pdf
* FINAL Coordination of Care Form English.doc
* FINAL Coordination of Care Form English.pdf
* FINAL Coordination of Care Form Spanish.doc
* FINAL Coordination of Care Form Spanish.pdf
* FINAL Coordination of Care Form Tagalog.doc
* FINAL Coordination of Care Form Tagalog.pdf
* FINAL Coordination of Care Form Viet.doc
* FINAL Coordination of Care Form Viet.pdf
* Interpreter Services Auth Form.pdf
* Medi-Cal Behavioral Health Transition of Care Form.doc
* MediCal Grievance and Appeal Forms.pdf
2015-10-09
* MFT Eligibility Verification Form.pdf
2015-10-09
* Sample - Discharge Summary.docx
2017-04-25
* Sample - Initial Assessment.docx
2017-04-25
* Sample - Med Management Progress Note.docx
2017-04-25
* Sample - Progress Note.docx
2017-04-25
* Sample - Treatment Plan.docx
2017-04-25
* Sample Psych Testing Request Form 012016.pdf
2016-02-24
* Psych Testing Guidelines.pdf
2016-02-24
* Medi-Cal Psych Testing Request Form 1.2016.pdf
2016-02-29
* Authorization To Use or Disclosed PHI Form.doc
2016-11-01
* NOA-A English.docx
2017-05-30
* NOA-A Tagalog Rv 11 01 16.docx
2016-12-20
* NOA-A Spanish Rv 11 01 16.docx
2016-12-20
* NOA-A Vietnamese.docx
2017-12-22
* NOA-A Arabic Rv 11 01 161.docx
2016-12-20
* Beneficiary Packet Materials Order Form rev2-20-18.pdf
2018-03-01
* BHS Serious Incident Report (doc)
2018-07-13
* BHS Serious Incident Report of Findings (doc)
2018-07-13
* CARE PLAN INFORMED CONSENT PSYCHOTROPIC MEDICATION.pdf
2018-02-01
* Demographic Form Fill - Required Fields (pdf)
2018-12-06
* Demographic Form Fill (docx)
2018-12-06
* Example - Outpatient Authorization Request - Therapists (docx)
2018-12-11
* Outpatient Authorization Request Form - Therapists (doc)
2018-12-03
* Outpatient Authorization Request Form - Therapists (pdf)
2018-12-03
* Outpatient Authorization Request Form Therapists - Required Fields (pdf)
2018-12-13
* Outpatient Authorization Request - Psychiatry Form (pdf)
2018-12-03
* Outpatient ECT Authorization Request (doc)
2018-08-24
* Outpatient ECT Authorization Request - Form Fill (pdf)
2018-08-24

Manuals

Name Description Date
* FFS Provider Operations Handbook (pdf)
Revised 10/31/2018 2018-10-30
* Inpatient Operations Handbook (pdf)
Revised 05/16/2017 2018-09-24

Quick Reference

Review - Outpatient

Name Description Date
* Beneficiary Packet Materials Order Form (pdf)
2018-03-01
* DHCS Reasons for Recoupment FY 17-18 (pdf)
2017-11-06
* Documentation Tip Sheet (pdf)
2016-09-15
* Record Keeping and Treatment Record Requirements (pdf)
2017-08-07
* Site Review Tool (pdf)
2018-02-22
* Treatment Record Review Tool (pdf)
2017-05-10

Review - Inpatient

Date Description Date
* Inpatient Professional Service Documentation Guide (pdf)
2018-07-12
* Inpatient Review Tool (pdf)
2017-08-07