Behavioral Health Staff: Forms & Policies
23-05: County Behavioral Health Intergovernmental Transfer (IGT)
CalAIM
Policy 23-05: Policy 23-05 County Behavioral Health Intergovernmental Transfer (IGT)
New Policy: July 14, 2023
5150 Certification Review Hearing (AB 2275): 23-04
Compliance
Policy 23-04: 5150 Certification Review Hearing (AB 2275)
Attachment A: Contact Information
Attachment B: Patient Rights Advisement
Attachment C: Hearing Record and Decision Form
New Policy: January 1, 2023
Utilization Management (UM), Audit, Oversight and Recoupment Standards for Substance Use Disorder (SUD) Services: 23-03
Compliance
Attachment A: CalMHSA SUD UR/Audit Tool
New Policy: February 3, 2023
Supersedes:
Policy 20-05: Utilization Management Program and Authorization of
SMHS
Utilization Management (UM) & Audit, Oversight, Recoupment Standards (SMHS): 23-02
Compliance
Utilization Management (UM) & Audit, Oversight, Recoupment Standards (SMHS)
Attachment A: CalMHSA SMHS UR/Audit Tool
New Policy: January 31, 2023
Supersedes:
Policy 20-05 Utilization Management Program and Authorization of
SMHS
Electronic Communications Policy (General Guidelines) 22-06
HIPAA
22-06 Electronic Communications (General Guidelines): Policy
Attachments:
Attachment A: Deidentifying Protected Health Information
Attachment B: Protocol for E-mail Usage (for staff)
Attachment C: Sending Secure E-mails
For additional guidance on electronic communication with clients, please see Policy 22-07 Electronic Communication (Client Communication).
New Policy: October 14, 2022
BHRS Naloxone Policy 22-05
AOD
BHRS Naloxone Policy: Policy 22-05
Attachment A: BHRS Pharmacy Naloxone Log
Attachment B: Clinic/Program Naloxone Log
Attachment C: Naloxone Staff Training Tracker
New Policy: September 15, 2022
Specialty Mental Health Services Provider Network (SPPN): 21-02
CLINICAL
Specialty Mental Health Services Provider Network (SPPN): 21-02
- Attachment A: Adult SPPN referral form
- Attachment B: Youth SPPN referral form
- Attachment C: SPPN Treatment Plan Update form
NEW POLICY: October 28, 2021
Documents established practice effective June 1, 2021
COVID-19 Testing Policy: 20-11
ADMINISTRATION
COVID-19 Testing Policy: 20-11
NEW POLICY: November 12, 2020
EFFECTIVE DATE: This policy is effective as of November 18, 2020.
POSTED DATE: December 22, 2021
Assignment of On-Call Work for BHRS Staff Divisional: Policy 21-01
Clinical
Assignment of On-Call Work for BHRS Staff : 21-01
Original policy date: May 12, 2021
Amended: October 6, 2022
Psychiatry Residency Training Program – Moonlighting Regulations 94-04
Medical Psychiatric
Policy: September 16, 1994
Updates: December 8, 2004; July 25, 2005; September 18, 2020
MHSA Issue Resolution Process: 20-10
OTHER
MHSA Administration and Components: 20-09
OTHER
MHSA Administration and Components: 20-09
ATTACHMENTS: MHSA Steering Committee Roles and Responsibilities
NEW POLICY: June 4, 2020
AMMENDED: October 15, 2021
Full Service Partnership: 20-08
OTHER
Full Service Partnership: Policy 20-08
NEW POLICY: May 11, 2020
Utilization Management of Inpatient Psychiatric Services: 20-06
Clinical
UM of Inpatient Psychiatric Services Policy: 20-06
Attachment A: Acknowledgment Notification Responsible | 20-06_Attachment B: Concurrent Documentation Required| Attachment C: Acknowledgment Notification Non-responsible
NEW POLICY: February 4, 2020; Technical Edit February 24, 2020;
Amended November 5, 2020
Attachment A: Technical Edit February 10, 2023
Authorization of Adult Residential Services: 20-02
Admission Referral
Authorization of Adult Residential Services Policy: 20-02
- Attach A: Adult Residental Auth Form
- Attach B: Electronic Community Referral
- Attach C: Adult Residential Progress Summary
Resources: Process changes have occured since this webinar consult with your BHRS Adult Team contact person Presentation |Video
NEW POLICY: January 17, 2020
Authorization of Youth Specialty Mental Health Services (SMHS): 20-04
Admission Referral
Authorization of Youth Specialty Mental Health Services (SMHS) Policy: 20-04
Attachments:
- A. TBS Authorization Form
- B. Service Authorization Request Form | Printable Version
- C. TBS Utilization Request Form
- D. TBS Assessment Extension Authorization
- E. TBS Assessment Authorization
- F. TBS Authorization Request Workflow
NEW POLICY: January 9, 2020
Attachments A, D, E: Technical Edit February 18, 2021 Attachment
F: added February 18, 2021
Medication Monitoring for Youth: 20-07
Medical Psychiatric
Medication Monitoring for Youth Policy: 20-07
NEW POLICY: January 8, 2020
Utilization Management Program and Authorization of Specialty Mental: 20-05
Compliance
UM Program: SMHS Policy: 20-05
NEW POLICY: January 9, 2020
Technical Edit July 17, 2020; Amended November 5, 2020
Provider Directory: 19-06
Compliance
Provider Directory Policy: 19-06
BHRS Directory Link https://www.smchealth.org/BHRSProviders
New Policy: December 18, 2019
Expedited Pre‐Service Organizational Determinations: 19-03
Managed Care
Expedited Pre‐Service Organizational Determinations: Policy 19-03
New Policy: August 28, 2019
Standard Pre‐Service Organizational Determinations: 19-02
Managed Care
Standard Pre‐Service Organizational Determinations: Policy 19-02
New Policy August 28, 2019
Consumer Problem Resolution & NOA: 19-01
Client Rights
Consumer Problem Resolution & NOA: 19-01 Policy 19-01
SUPERSEDES: 04-10 Notice of Action, 03-03 Consumer Problem Resolution System
New Policy June 2019, Technical edits and Translated attachments
added, October 10, 2019; Technical Revision January 9, 2020
Attachment A: Amended January 9, 2020,
Attachment B: Technical Edit March 12, 2021, Technical Edit March 14, 2021; Technical Edit September 24, 2021
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- Templates for reason for issuing NOABD, Why we denied your request.
- Guide to Using the AVATAR NOABD / NAR Form
- Read more
CANS & PSC-35 Implementation: Memo 01-22
Clinical
CANS & PSC-35 Implementation: Memo 01-22: CANS and PSC-35 - All Providers
Supersedes: Memo 01-18: County Mental Health Staff | Memo 02-18: Contractor Mental Health Agencies Memo 03-18: CANS & PSC-35- all providers
New Memo: June 24, 2022
Network Adequacy Standards 18-02
Compliance
Cultural Humility, Equity, CLAS, 18-01
Clinical
Delegation Oversight & Audit Program: 17-02
Compliance
Delegation Oversight & Audit Program: 17-02
Attachment: A. Contractor Attestation
Updated: October 24, 2017. Technical update: 12-18-2019
INDEX of CURRENT POLICIES and PROCEDURES BHRS
Other
72-Hour Holds – Authorization to Write: 97-05
5150/Safety/Risk Policies
72-Hour Holds – Authorization to Write
Attachments: None
Original policy date: 5/3/97
Amended: April 9, 2008, September 19, 2018; October 1, 2021
Amendment of Protected Health Information (PHI), Client Request: 03-09
HIPAA
Amendment of Protected Health Information (PHI), Client Request: 03-09
Attachments:
Attachment: A. Request to Amend Protected Health Information
Attachment: B. Response to Request To Amend Protected Health Information
Attachment: C. Statement of Disagreement/Request to Include Amendment Request and Denial with Future Disclosures
Attachment: D. Notification of Amendment to Protected Health Information
Application for Services and Consent to Treatment: 96-15
HIPAA
Application for Services and Consent to Treatment: 96-15
Attachments:
Application for Services and Consent to Treatment: 96-15, Attachment A, Treatment Consent & Notice of Privacy Practices: English
Application for Services and Consent to Treatment: 96-15, Attachment A, Treatment Consent & Notice of Privacy Practices: Spanish
Application for Services and Consent to Treatment: 96-15, Attachment A, Treatment Consent & Notice of Privacy Practices: Tagalog
Application for Services and Consent to Treatment: 96-15, Attachment A, Treatment Consent & Notice of Privacy Practices: Tongan
Application for Services and Consent to Treatment: 96-15, Attachment, B. Minor Client Legal Status and Implications for Consent
Application for Services and Consent to Treatment: 96-15, Attachment, C. GGRS Clients Mentally Incapable of Giving Consent
Assaults on Clients: Suspected or Reported: 01-03
5150/Safety/Risk Policies
Assaults on Clients: Suspected or Reported: 01-03
Attachments:
Attachment A. Dependent Adult or Elder Abuse Reporting Agreement (for Employees)
Attachment B. Child Abuse Reporting Agreement (for Employees)
Attachment C. Table - Mandated Reporting of Dependent Adult and Elder Abuse
Attachment D. Emergency and Mandated Phone Numbers for Reporting Dependent Adult/Elder
Attachment E. Police Phone Numbers for Reporting Purposes (Non Emergency)
Attachment J. Community Resources Crisis Lines
Attachment K. Instructions for Residential Care Facilities
Authorization to Host: HS A-5
Administration
Hosting Authority Policy
Attachments: Authorization To Host Form
Previously BHRS Policy 00-07: Authorization to Host
Original policy date: 2/11/00
Amended 4/11/07; Technical Edit 7/9/14
Superseded by County Health Policy HS A-5 on 10/25/17; Amended 1/24/22
Bilingual Salary Differential -Per San Mateo County Policy: 01-08
Administration
Blood Withdrawal by Community Mental Health Nurses: 95-06
Medical Psychiatric
Change of Clinician Request: 98-01
Client Rights
Change of Clinician Request: 98-01
Attachments:
Change of Clinician Request: 98-01, Attachment: A. Request for Change of Provider – English
Change of Clinician Request: 98-01, Attachment: B. Request for Change of Provider – Spanish
Change of Clinician Request: 98-01, Attachment: C. Request for Change of Provider – Tagalog
Change of Clinician Request: 98-01, Attachment: D. Request for Change of Provider – Chinese
Claims Processing Guidelines and Procedures: 07-04
Financial
Claims Processing Guidelines and Procedures: 07-04
Attachments:
Claims Processing Guidelines and Procedures: 07-04, Attachment: A. Explanation of Payment (EOP) Procedure
Claims Processing Guidelines and Procedures: 07-04, Attachment: B. Receipt and Processing of Claims from Providers
Claims Processing Guidelines and Procedures: 07-04, Attachment: C. Processing Payable MHP Claims
Claims Processing Guidelines and Procedures: 07-04, Attachment: D. Processing Denied MHP Claims
Claims Processing Guidelines and Procedures: 07-04, Attach E: Investigating Pended Claims before Final EOP Run
Claims Processing Guidelines and Procedures: 07-04, Attachment: G. Adjusting overpaid and underpaid claims
Claims Processing Guidelines and Procedures: 07-04, Attach I_Procedure for setting up providers and fees schedules in MSO
Claims Processing Guidelines and Procedures: 07-04, Attach J :Processing Payable MHP Claims
Claims Processing Guidelines and Procedures: 07-04, Attach L: Procedure for Reimbursing Provider Claims for Telehealth and Phone
Claims Processing Guidelines and Procedures: 07-04, Attach M: Procedure for Identifying, Reporting, and Recovering Mental Health
Claims Processing Guidelines and Procedures: 07-04 , Attachment N: Procedure for System Maintenance
Client Access to Protected Health Information (PHI): 00-06
HIPAA
Client Access to Protected Health Information (PHI): 00-06
Attachements:
Attachment A. Request for Access to Protected Health Information
Attachment A. Request for Access to Protected Health Information, Spanish
Attachment A. Request for Access to Protected Health Information, Tagalog
Attachment B. Log of Requests for Access to Protected Health Information
Client Insurance Information and Financial Participation: 03-12
Financial
Client Insurance Information and Financial Participation: 03-12
Attachments:
Attachment: A. Uniform Method of Determining Ability to Pay (UMDAP) Fee Schedule and Asset Allowance Schedule
Attachment. B. Roles and Responsibilities for Client Information and Financial Screening
Attachment: C. San Mateo Mental Health Guide to Payor Financial Information (PFI) Requirements
Attachment: E. What You Need To Know about Payment, English
Attachment: E. What You Need To Know about Payment, Spanish
Attachment: D. Payer Financial Information
Attachment: F. Therapeutic Fee Adjustment Request forms
Documentation Requirements for all SMHS, DMC and DMC-ODS Services
Compliance
Policy 22-04: Documentation Requirements or all SMHS, DMC, and DMC-ODS Services: Policy
Confidentiality/Privacy of Protected Health Information (PHI): 03-01
HIPAA
Confidentiality/Privacy of Protected Health Information (PHI): 03-01
Attachments:
A. Declaration of Notice of Confidentiality
B. Authorization for Use or Disclosure of Health Information (Mental Health): English | Spanish | Chinese | Tagalog | Tongan | Russian
C. Authorization for the Verbal Release of Client Information (Mental Health): English | Spanish | Chinese | Russian | Tagalog | Tongan
F. Exchange of Information: Principles and Definitions
G. Exchange of Information: Guide to Sharing
H. Authorization for Use or Disclosure of Protected Health Information (AOD Services): English | Spanish | Chinese | Russian | Tagalog | Tongan
Consumer Problem Resolution Process: 03-03
Client Rights
Obsoleted by 19-01 June 24,
2019
Consumer/Client and Family Member Stipends for Services to Behavioral Health and Recovery Services: 06-02
Client Rights
Contracts, Requests for Proposals (RFP), and Waivers of RFP Process: 97-06
Contracts
Contracts, Requests for Proposals (RFP), and Waivers of RFP Process: 97-06
Attachments:
Contracts, Requests for Proposals (RFP), and Waivers of RFP Process: 97-06, Attachment A- Contracting Methodologies
Contracts, Requests for Proposals (RFP), and Waivers of RFP Process: 97-06, Attachment B, Competitive Awards Procedure
Contracts, Requests for Proposals (RFP), and Waivers of RFP Process: 97-06, Attachment D, Public Notice
Determining Responsibility for Involuntary Treatment and Out-of-County Services: 94-06
Admission Referral
Disclosure of Protected Health Information (PHI), Minimum Necessary: 03-04
HIPAA
Disclosure of Protected Health Information (PHI), Minimum Necessary: 03-04
Attachments:
Attachment: B. Routine Requests and the Degree of Disclosure Allowed
Attachment: C. Management Information System (MIS) – Outline of Access by Function
Attachment: A. Individuals and the Conditions of their Minimum Necessary Access by Workforce Class
Disclosures of Protected Health Information (PHI) with Client Authorization: 03-06
HIPAA
Disclosures of Protected Health Information (PHI) with Client Authorization: 03-06
ATTACHMENTS:
See Policy 03-01:
Confidentiality/Privacy of Protected Health Information
(PHI)
• Attachment B: Authorization for Use or Disclosure of Protected
Health Information
• Attachment C: Authorization for the Verbal Release of Client
Information
Disclosures of Protected Health Information (PHI), Incidental: 03-05
HIPAA
Disclosures of Protected Health Information (PHI), Request for an Accounting: 03-07
HIPAA
Education Leave/Training Guidelines: 96-06
Medical Psychiatric
Education Leave/Training Guidelines: 96-06
Attachments:
Attachment: A. Request for Educational Leave with Pay
Attachment: B&C. Request for Tuition Reimbursement (County form & Guidelines)
Attachment: D. Request for Reimbursement for Professional Dues, Fees, CME or CEU Courses, or Clinical Training Materials
Attachment: E. Educational Leave/Training Guidelines
Eligibility for Planned (non-emergency) SMC MH Services for Individuals Who Have Private Insurance: 03-13
Admission Referral
Email Use: 03-11
HIPAA
Flexible Funds: 00-03
Clinical
Flexible Funds: 00-03
Attachments:
Attachment: A. Youth Flexible Funds Application Information
Attachment: B. Child-Youth Flexible Funds Request Authorization Form
Attachment: C. Youth Transition, Adult/Older Adult Flexible Funds Application Information
Attachment: D. Youth Transition, Adult/Older Adult Flexible Funds Request Authorization Form
Flexible/Alternative Work Hours: 01-02
Administration
Retired 10/12/21
Original policy date: 7/3/01
Last review: 8/13/08
Inpatient Services to Beneficiaries of Other Counties: 00-09
Admission Referral
Superseded by UTILIZATION MANAGEMENT OF INPATIENT PSYCHIATRIC SERVICES: 20-06
Linkages between Outpatient Clinics and Psychiatric Emergency Services (PES) about Adult MH Clients Open to Region: 02-01
5150/Safety/Risk Policies
Linkages between Outpatient Clinics and Psychiatric Emergency Services (PES) about Adult MH Clients Open to Region: 02-01
Attachments:
Attachment B. After Hours Phone Numbers
Linkages between Outpatient Clinics and Psychiatric Emergency Services (PES) about Adult MH Clients Open to Region: 02-01
Attachment C: Fax for PES & 3AB
Medication Authorization for Dependent Children (W&I Code, Section 300): 99-02
Medical Psychiatric
Medication Authorization for Dependent Children: 99-02
Attachments: A. JV 220 | B. JV-220-A | C. JV-220-B | D. JV-221 | E. JV-222 | F. JV 223
Original policy date: 1/12/99
Last review: 1/27/20107
Medication Room Management: 99-03
Medical Psychiatric
Medication Room Management: 99-03
Attachments:
Attachment: A. Controlled Substance/Emergency Supply Record
Attachment: E. Medication Room Inspection
Attachment: B. Medication Samples Log
Attachment: C. Sample Medication Label
Attachment: D. Record of Medication Storage and Removal for Destruction
Attachment: F. Protocol: Storage of Medications until Retrieval by Client
Attachment: G. Registration/Permit Application for Medical Waste Generation, Storage and Treatment
Attachment: H. Registration, Limited Quantity Hauling Exemption
Attachment: I. Limited Quantity Hauling Exemption Medical/Pharmaceutical Waste Tracking Document
Mental Health Nurse Practitioner Protocols: 97-10
Medical Psychiatric
Credentialing and Re- Credentialing Providers: 19-08
Compliance
Credentialing and Re- Credentialing Providers Policy 19-08
Attachments:
- A. Contractor Monthly Credentialing Verification Spreadsheet
- B. Attestation BHRS Staff and On-site Contractors
- C. Attestation Contractors
- D. Acknowledgment of Receipt (BHRS Policies)
- E. BHRS Form 700 – Contractor Agency
- F. Health Policy A-14: Conflict of Interest, Incompatible Activities and Outside Employment for Employees
- G. Health Policy A-14 (Attachment 1): Employee Statement
- H. BHRS Attestation for Outside Employment for Health Policy A-14
Original Policy Date: December 31, 2019,
Amended: Technical Edit January 9, 2020; Technical Edit
November 5, 2020; Technical Edit November 5, 2020
Attachment F: updated June 7, 2021
Attachment G: updated February 17, 2023
Required Policies For New Staff to Review
BEHAVIORAL HEALTH CONFIDENTIALITY
- Policy 00-06 Client Access to Protected Health Information
- Policy 03-01 Confidentiality/Privacy of Protected Health Information
- Policy 03-11 E-Mail Use
- BHRS Compliance Plan
- BHRS Code of Conduct
- Policy 91-05 Compliance with Documentation Standards
CLINICAL STAFF ONLY
- Policy 03-02 Notice of Privacy Practice
- Policy 03-04 Disclosure of Protected Health Information, Minimum Necessary
- Policy 03-05 Disclosure of Protected Health Information, Incidental
- Policy 03-06 Disclosure of Protected Health Information with Client Authorization
- Policy 03-07 Disclosure of Protected Health Information, Request for an Accounting
- Policy 03-08 Restrictions on Use or Disclosure of Protected Health Information Client Request
- Policy 03-09 Amendment of Protected Health Information, Client Request
Notice of Action: 04-10
Client Rights
Obsoleted by 19-01 June 24,
2019
Notice of Privacy Practices: 03-02
HIPAA
Notice of Privacy Practices Policy: 03-02
Attachment A: Summary of Privacy Practices: English | Spanish | Chinese | Tagalog | Tongan | Russian
Attachment B: Consent to Treatment & Acknowledgement of Receipt of Notice of Privacy Practices: English | Tagalog | Spanish | Tongan | Chinese | Tagalog | Russian
Petty Cash Procedures: Policy 13-02
Financial
Pharmaceutical/Vendor Representatives Access and Accountability: 04-06
Medical Psychiatric
Procedures for Non-SMMC Inpatient Psychiatric Treatment: 99-08
Admission Referral
Superseded by UTILIZATION MANAGEMENT OF INPATIENT PSYCHIATRIC SERVICES: 20-06
Provider Contracts: 98-03
Managed Care
Superseded by policy 19-07
Psychiatric Utilization Management Committee: 92-12
Admission Referral
Quality Improvement Compliance Review of Outpatient Provider Services: 98-11
Compliance
Quality Improvement/Peer Review of Cases in which Death has Resulted from Suicide, Homicide or Suspicious Causes: 00-10
5150/Safety/Risk Policies
Restrictions on Use or Disclosure of Protected Health Information (PHI), Client Request: 03-08
HIPAA
Restrictions on Use or Disclosure of Protected Health Information (PHI), Client Request: 03-08
Attachments:
Attachment: A. Request for Special Restriction on Use or Disclosure of Protected Health Information
Attachment: B. Response to Request for Special Restriction on Use or Disclosure of Protected Health Information
Services to Clients in Primary or Preferred Languages: 99-01
Clinical
Standards of Care in an Integrated Behavioral Health System: 11-01
Clinical
Standards of Care in an Integrated Behavioral Health System: 11-01
Attachments:
Standards of Care in an Integrated Behavioral Health System: 11-01, Attachment B: Assessment and Integration of Spiritual Intere
Standards of Care in an Integrated Behavioral Health System: 11-01, Attachment A: Standards of Care for AOD Providers
Subpoenas to Release Records: 96-14
HIPAA
Subpoenas to Release Records: 96-14
Attachments:
Attachment: A. Subpoena Review Checklist
Attachment: B. Sample Cover Letter for Forwarding Records per Appropriate Subpoena and Release
Attachment: C. Sample Letter When No Release Accompanies Subpoena and All Documents Are Being Returned
Attachment: D. Sample Letter for Returning Subpoena Previously Responded To
Telecommuting: 96-07
Administration
Retired 10.12.21