AQIS - CYPBH MHRS Downloads

All consumer posters and brochures for Medi-Cal clinic sites are downloadable from this page.  Please contact AQIS CYPBH at AQISSupportTeams@ochca.com or call (714) 796-0123 for any questions. Patient's rights posters and brochures are in downloadable format at the  Patients' Rights Advocacy Services website.  Please contact Patients Rights Advocacy Services at (714) 834-5647 for any additional questions.

Clinical Information

    Caregiver Intake Questionnaires   8/7/19 

• Caregiver Intake Questionnaire_ARABIC
• Caregiver Intake Questionnaire_ENGLISH
• Caregiver Intake Questionnaire_FARSI
• Caregiver Intake Questionnaire_KOREAN
• Caregiver Intake Questionnaire_SPANISH
• Caregiver Intake Questionnaire_VIETNAMESE

    Clinical Resources

• BH Provider Handbook Coding Manual Version 11(Effective November 2020)
• Clinician Coding Guide (Non-MD)  Effective 4/4/18
• Clinician Coding Guide (MD)   Effective 4/4/18
• CYPBH Annual Provider Training - Forms/Resources/Notes(County Version) Effective 12/2017
• CYPBH Annual Provider Training-Forms/Resources/Notes(Contract Version) Effective 12/2017
• DHCS Therapeutic Mental Health and Recovery Services (TBS) Documentation Manual  Effective 10/1/2009
• EPSDT Documentation Manual
• Legal Classes and Court Conservator Status
• Medi-Cal Manual for Intensive Care Coordination (ICC)  Effective 1/1/18 
• New Provider Training-Forms/Resources/Notes (County Version)
• New Provider Training-Forms/Resources/Notes (Contract Version)
• Revised Encounter Document FAQ 1-7-14
• Service Strategies

     Clinical Supervision

 

• Clinical Supervision Reporting Form 2022.1.14
• MHRS-AQIS A Guide to Clinical Supervision 2020.08.12

Change of Provider/Second Opinion Log - NEW  

• CYPBH Change of Provider/Second Opinion Log - County Clinic Form
• CYPBH Change of Provider/Second Opinion Log - Contract Clinic Form

 Medication Consents [F346-7921] - 2019

• Arabic
• Chinese
• English 
• Farsi   
• Korean 
• Spanish 
• Vietnamese 

    Outcome Measure Workflows 01/13/2020

• County Outcomes Workflow
• Contract Outcomes Workflow

    Pediatric Symptom Checklist 

• Click here for PSC Checklists

    Psychiatrist Information/Downloads

• MHRS Formulary
• CYS Prescribing Practices
• Guide to Psychotropic Medication Forms-JV-217-Info-Judicial Council  (Effective 1/1/2018)  
• JV-220 Application Regarding Psychotropic Medication  (Typically completed by SSA Staff or Probation Staff) (Effective 1/1/2018)
• JV-220 (A) Prescribing Physician Statement-Attachment (1/1/2018)
• JV 220 (B) Physician's Request to Continue Medication—Attachment (Effective 1/1/2018)
• Treatment Authorization Request (TAR)

Continuity of Care  

• Continuity of Care P&P 09.01.08
• AQIS Continuity of Care Request Form
• Continuity of Care - Training 

Medi-Cal Information

• MHRS Medi-Cal Provider Information Page
• Medi-Cal Mental Health Plan - Provider Directory
• Provider Directory - Quick Guide [For Providers]
• Provider Directory - Translation Features

 

Advance Health Care Directives (F346-705)

• Arabic
• English
• Farsi
• Korean
• Spanish
• Vietnamese

Authorization to Use or Disclose Protected Health Information (PHI) 

Please click links below to access the most up-to-date Authorization to Use or Disclose (ATD) PHI forms

• For Patient/Client use for Medical Records Request from Custodian of Records
• Revocation of Authorization to Use or Disclose Public Health Information 
• For Clinic Use - County Intranet

    EPSDT-TBS Brochures (MC-003-DHCS)

 

• Arabic 
• English
• Farsi
• Mandarin Chinese
• Korean
• Spanish
• Vietnamese

 

   Grievance or Appeal Form (F346-706)  (October 2017)

• Arabic
• Chinese
• English
• Farsi
• Korean
• Spanish
• Vietnamese

Grievance Tracking Form

    Grievance or Appeal Process Posters (October 2017)

• Arabic
• Chinese
• English - updated 1/27/22
• Farsi
• Korean
• Spanish - updated 1/27/22
• Vietnamese

    HIPAA - Notice of Privacy Practices

• Link to Notice of Privacy Practices  (County Operated Provider Use Only) 

 

Medi-Cal Handbook

• Arabic Small Print  Large Print 
• English  Small Print Large Print
• Farsi Small Print  Large Print
• Korean Small Print Large Print
• Spanish Small Print Large Print
• Vietnamese Small Print  Large Print
• Audio Version (Arabic, English, Farsi, Korean, Spanish, Vietnamese) 

    Mental Health Plan Intake/Advisement Checklist (F346-753) (October 2017)

• Arabic
• English
• Farsi
• Korean
• Spanish
• Vietnamese

Forms - FOR COUNTY OPERATED PROVIDER USE ONLY

Car Seat Safety Flyers (County Use Only)   

 

Description	Chinese	English	Korean	Spanish	Vietnamese
National Voter Registration Act (NVRA) Preference Forms National Voter Registration FAQs (County Operated Provider Use Only)

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