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Medi-Cal Certification

P&P's Applicable to Medi-Cal Certifications and Re-Certifications


Forms and Training Related to Medi-Cal Certification
Contract Provider Medi-Cal Certification Applicationupdated8/19/2020
County-Owned and Operated Provider Application Form (DHCS 1736) Instructions
County-Owned and Operated Provider Application (DHCS 1736)
SD/MC Certification Protocol DHCS  
Medi-Cal Certification & Recertification Training (PowerPoint)  
A) Protected Health Information  Policy #
Accounting for Disclosures of Protected Health Information 05.05.03 (MHRS) 
Authorization and Revocation of Authorization to Use and Disclose PHI (Intranet Only)    IV-7.04 (HCA)    
Missing/ Lost Charts 05.01.07 (MHRS)
Notice of Privacy Practices 02.05.01 (MHRS)
Notice of Privacy Practice Acknowledgement of Receipt 02.05.01 (MHRS)
Records Management and Maintenance  (Intranet Only) IV-4.04 (HCA)
Transport of Clinical Records 05.01.08 (MHRS)
Tracking Disclosures of PHI/ PHI Disclosure Tracking Log 05.05.02 (MHRS)
Use and  Disclosure of Protected Health Information 05.05.02 (MHRS)
Billing Compliance 07.01.02 (MHRS)
Documentation of Services 05.01.03 (MHRS)
Fraud and Abuse 07.01.01 (MHRS)
B) Personnel Policies and Procedures Policy #
Code of Conduct Booklet (County Intranet only)  
Code of Conduct Policy and Procedures (County Intranet Only) I-9.05 (OOC)
Screening for Ineligible Persons (County Intranet Only) 16.09  (OOC)
Sanctions for Privacy and Security Violations (Intranet Only) I-24.02 (OOC)
Verification of Individual NPI Numbers and Professional Licenses  (Intranet Only) new 07,0.01 (MHRS)
C) General Operating Procedures Policy #
Emergency Evacuations V-4.03 (HCA)
Key Control and Card Key Systems (Intranet Only) V-4.02 (HCA)
D) Maintenance Policy to Ensure Safety to Ensure Safety of Beneficiaries & Staff Policy #
HCA Managers V-4.00 (HCA)
E) Service Delivery Policies Policy #
Program Description for Children and Youth Services  
Interpretation Services Poster    
F) Unusual Occurrences Policy #
Reporting of Unusual Occurrences to Department of Mental Health  (Intranet only) 06.01.01(MHRS)
Special Incident Report P&P (Intranet only) and Form F042-01.2089 (Intranet only) IV-1.03 (HCA)
G) Category 8 - Pharmaceutical Services Policy #

Outpatient Clinic Medication Rooms – Receipt, Storage, Administration, Disposal and Accountability of Medicationupdated

Medication Refrigerator & Room Temperature Record (F346-709) updated

Record of Medication Receipts, Storage, Administration and Disposal Non-Controlled (F346-710) updated

Record of Medication Receipts, Storage, Administration and Disposal Controlled (F346-710C) new

Daily Record of Medication Storage (Controlled) new

OC MHRS Medication Room Annual Review Checklist updated

Psychotropic Medication Consent Forms 02-04-02 (MHRS)
Psychotropic Medication Consent (English)  
Psychotropic Medication Consent (Farsi)  
Psychotropic Medication Consent (Korean)  
Psychotropic Medication Consent (Spanish)  
Psychotropic Medication Consent (Vietnamese)  
OC JV 220 Fillable SSA Dependency