Behavioral Health Staff: Forms & Policies

Policy: 26-02 Quality Improvement Committee

Attachment A: QIC Subcommittee List and Descriptions

Policy: 26-03 Quality Management (QM) Program Description

Attachment A : Description of Performance Monitoring Activities

Policy: 25-06 External Communications – Public Communications, Letterhead, Press Releases, and Media Campaign Policy

Attachment A: BHRS Communications Policy Workflow
Attachment B: CSM Photo/Video/Audio and Personal Narrative Consent & Release Form
Attachment C: Public Notice of Photo/Video Release for Large Events

Policy: 25-03 5270 Certification Review Hearings 

Attachment A: Certification Review Hearing Information
Attachment B: Certification Review Hearing Record and Decision Form

Policy: 24-04 Service Verifications

Attachment A: Sample Verification of Services Letter
Attachment B: Sample Phone Script
Attachment C: Sample Service Verification Report

Memorandum of Understanding between San Mateo Health Commission d/b/a Health Plan of San Mateo and Behavioral Health & Recovery Services. MOU_MHP-MCP_HPSM

Memorandum of Understanding between San Mateo Health Commission d/b/a Health Plan of San Mateo and San Mateo County Behavioral Health & Recovery Services DMC-ODS. MOU_DMC ODS-MCP_HPSM 

Added 11/15/2024

Annual Reports
San Mateo County 2025 Annual MOU Report

Quarterly Reports
San Mateo MHP DMC-ODS MOU Quarterly Reporting 2026 Q1  

Policy 24-01: Graduate Medical Education (GME)

Attachement A: BHRS GME Org Chart
Attachment B: Special Review Process
Attachment C: ACGME Duty Hour Standards (Section VI.F.1-4. of Common Program Requirements)

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

Policy: 23-02 Utilization Management (UM) & Audit, Oversight, Recoupment Standards (SMHS)

Attachment A: CalMHSA SMHS UR/Audit Tool

Policy : 22-06 Electronic Communications (General Guidelines)

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). 

Policy: 21-02 Specialty Mental Health Services Provider Network (SPPN)

Attachment A: Adult SPPN Referral Form
Attachment B: Youth SPPN Referral Form
Attachment C: SPPN Treatment Plan Update Form

SMC Telework Guide 

BHRS Telehealth Informed Consent Form

English |Spanish | Tagalog | Russian | Tongan

Implemented 03-24-2020

Policy: 20-04 Authorization of Youth Specialty Mental Health Services (SMHS)

Attachment A: TBS Authorization Request Form
Attachment B: TBS Service Authorization Request Form I Printable Version
Attachment C: TBS Utilization Review Form
Attachment D: TBS Assessment Extension Authorization
Attachment E: TBS Assessment Authorization
Attachment F: TBS Authorization Request Workflow

Policy: 19-04 Utilization Management Program – Interrater Reliability Testing

Attachment A : Interrater Reliability Testing Protocol

Policy: 18-03 Utilization Management Program

Attachment A : UM Decision Workflow for Call Center
Attachment B: Affirmative Statement about Incentives

Policy : 18-01 Cultural Humility, Equity and Inclusion Framework; Implementation of CLAS Standards

Attachment A: BHRS and Health System Policies Relevant to the National CLAS Standards

Policy: 17-02 Delegation Oversight & Audit Program

Attachment A: Contractor Attestation

Policy: 05-08 Adverse Event Reporting
Attachment A​: SMC Ordinance 04272

Policy: 98-12 Agency Provider Certification - Medi-Cal
Attachment A: Medi-Cal Site Re/Certification Tool & Summary

Policy: 03-09 Amendment of Protected Health Information (PHI), Client Request

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

Policy: 96-15 Application for Services and Consent to Treatment

Attachment A: Consent to Treatment & Acknowledgement of Receipt of NPP
Spanish I Tagalog I Tongan
Attachment B: Minor Client Legal Status and Implications for Consent
Attachment C: GGRC Clients Mentally Incapable of Giving Consent

Policy: 01-08 Bilingual Salary Differential – Per San Mateo County Policy
Attachment​: Bilingual Salary Form

Cell Phone Usage: 01-01
Attachments: A. Client Acknowledgment | B. Cell Phone Voicemail Greeting Script |  C. Client Acknowledgment Spanish | D. Client Acknowledgment Chinese | E. Client Acknowledgment Tagalog

County Policies A36, B19, ISD

Policy: 95-07 Charting and Medication Guideline
Attachment A: Medication Monitoring Checklist

Policy: 07-04 Claims Processing Guidelines and Procedures

Policy: 03-12 Client Insurance Information and Financial Participation
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 D: Payer Financial Information
Attachment E: What You Need To Know about Payment for Mental Health Services Spanish

Policy: 03-16 Compliance and Delegation Oversight Committee

Attachment A : Compliance and Delegation Oversight Committee Charter

Policy: 03-01 Confidentiality/Privacy of Protected Health Information (PHI)

Policy: 06-02 Stipends for Individuals with Lived Experience and Family Members for Services Provided to San Mateo County Behavioral Health and Recovery Services
Attachment A: Consumer/Family Member Stipend Form Spanish

Policy: 96-13 Court Testimony by Psychiatrists

Attachment A: Psychiatrists Assigned to Testify in Court in the Absence of a Primary Psychiatrist

Policy: 93-11 Critical Incident Reporting

Attachment A: Incident Reporting Form
Attachment B: Breach Decision Tree

Policy: 94-06 Determining Responsibility for Involuntary Treatment and Out-of-County Services

Attachment A: The Greater Bay Area Mental Health Directors’ Policy for Determining Responsibility for the Provision of Involuntary Treatment of Out-of- County Services

Policy: 03-07 Disclosures of Protected Health Information (PHI), Request for an Accounting

Attachment: A: Request for an Accounting of Disclosures
Attachment: B: Response to Request for an Accounting of Disclosures
Attachment: C: Log of Accountable Disclosures

Policy: 96-06 Education Leave/Training Guidelines

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

Policy: 03-13 Eligibility for Planned (Non-emergency) SMC MH Services for Individuals Who Have Private Insurance

Attachment A: Summary Parity Info

Facsimile (FAX) Confidentiality: 01-07
Attachments: Facsimile (FAX) Confidentiality: 01-07: Attachment: Sample Cover Sheet​

Policy: 93-03 Initiating Temporary LPS Conservatorship

Attachment A: Physician’s Declaration

Policy: 02-01 Linkages between Outpatient Clinics and Psychiatric Emergency Services (PES) about Adult MH Clients Open to Region

Attachment A: Adult Regional Clinic/Specialty Team Unit Chief’s Phone and Fax Numbers
Attachment B: Adult Regional Clinic/Specialty Team After Hours Phone Numbers
Attachment C: Adult Outpatient Clinic/Specialty Team FAX of Client Information

Policy: 10-02 Medical Marijuana

Attachment A: Sample Medical Marijuana Treatment Agreement

Policy: 99-02 Medication Authorization for Dependent Children (W&I Code, Section 300)

Attachment A: JV 220
Attachment B: JV-220-A
Attachment C: JV-220-B
Attachment D: JV-221
Attachment E: JV-222
Attachment F: JV 223

Policy: 99-03 Medication Room Management

Attachment A : Controlled Substance/Emergency Supply Record
Attachment B: Record of Medication for Storage and Removal
Attachment C: Report of Quarterly Medication Room Inspection
Attachment D: Medical Waste Registration Application
Attachment E: Medical Waste Management Plan
Attachment F: Stock Medication Order Form
Attachment G : Long-Acting Injectable Medication Administration

Policy: 97-01 Mental Health Nurse Practitioner Protocols

Attachments A : Mental Health Nurse Practitioner Procedure
Attachment B : Mental Health Nurse Practitioner Drug Procedure

Policy: Petty Cash Procedures

Attachment C: Petty Cash Voucher
Attachment D: Petty Cash Operating Procedure Checklist
Attachment E: Petty Cash Policy Contacts

Policy: 90-08 Management of Threatening and Potentially Violent Behavior

Attachment A: Protocol: Management of Threatening and Potentially Violent Behavior

Policy: 93-10 Practice Standards (Scope of Practice)

Attachment A: Scope of Practice Matrix