00 – SUD Uniform Record Manual 07-01-19 (pdf)
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2019-09-03 |
01 – Uniform Record Manual 07-01-19 (pdf)
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Revised July 2019 |
2019-07-31 |
02 - Client File Order (pdf)
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Revised December 2020 |
2020-12-23 |
03 - Section 1 Detail 01-14-19 (pdf)
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2019-02-11 |
101a Instruction Client Tracking (pdf)
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Revised December 2020 |
2020-12-23 |
101b Client Tracking (pdf)
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Revised December 2020 |
2020-12-23 |
103 Instruction Medi-Cal Eligibility Printout (pdf)
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2019-02-11 |
104a Instruction Supplement Minor Children 04-12-17 (pdf)
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2018-01-24 |
104a Minor Children Form 04-12-17 (pdf)
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2018-01-24 |
104b-1 Instructions Brief Level of Care Screening Tool 05-01-2020 (pdf)
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Revised May 2020 |
2020-05-14 |
104b-2 Brief Level of Care Screening Tool Hard Copy 05-01-2020 (pdf)
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Revised May 2020 |
2020-05-14 |
104b-3 Brief Level of Care Screening Tool Form Fill 05-01-2020 (pdf)
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Revised May 2020 |
2020-05-14 |
104c-1 Instructions Adult Initial Level of Care Assessment (pdf)
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Revised December 2020 |
2020-12-23 |
104c-2 Adult Initial LOC Assessment Hard Copy (pdf)
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Revised December 2020 |
2020-12-23 |
104c-3 Adult Initial LOC Assessment Form Fill (pdf)
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Revised December 2020 |
2021-02-10 |
104d-1 Instructions Adolescent Initial Level of Care Assessment (pdf)
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Revised December 2020 |
2020-12-23 |
104d-2 Adolescent Initial LOC Assessment Hard Copy (pdf)
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Revised December 2020 |
2020-12-23 |
104d-3 Adolescent Initial LOC Assessment Form (pdf)
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Revised December 2020 |
2021-02-10 |
104e-1 Instructions Parent Guardian Initial Level of Care Assessment (pdf)
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Revised December 2020 |
2020-12-23 |
104e-2 Parent Guardian Initial LOC Assessment Hard Copy (pdf)
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Revised December 2020 |
2020-12-23 |
104e-3 Parent Guardian Initial LOC Assessment Form Fill (pdf)
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Revised December 2020 |
2020-12-23 |
105 Placement Fee Collection 4-12-17 (pdf)
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2017-05-01 |
106 Placement-ID-SS-Medi Cal Cards (pdf)
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2018-07-06 |
107a Instruction Financial Responsibility Info and MC SOC 05-01-2020 (pdf)
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Revised May 2020 |
2020-05-14 |
107b Financial Responsibility Information and MC SOC 05-01-2020 (pdf)
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Revised May 2020 |
2020-05-14 |
108 Placement - SanWITS Admission Profile 01-14-19 (pdf)
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2019-02-11 |
200 Section 2 Detail 07-01-19 (pdf)
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2019-07-26 |
201 Placement-consent to release 07-01-19 (pdf)
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2019-07-26 |
202 Placement-Admissions Agreement-Consent to Treatment 4-12-17 (pdf)
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2017-05-01 |
203a Instructions Client Rights and Complaints 05-01-2020 (pdf)
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Revised May 2020 |
2020-05-14 |
203b Client Rights and Complaints (pdf)
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Revised December 2020 |
2020-12-23 |
204 Placement-42 CFR Written Summary Requirements 7-2-18 (pdf)
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2018-07-06 |
205 Placement-Notice of Privacy-HIPAA 4-12-17 (pdf)
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2017-05-01 |
206 Placement-Consent to Follow up 4-12-17 (pdf)
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2017-05-01 |
207 Placement-Consent for photo-tv-video 4-12-17 (pdf)
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2017-05-01 |
209a Instruction Acknowledgement of DMC-ODS Handbook Practice Guidelines and Provider Directory 03-07-19 (pdf)
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2019-03-21 |
209b Acknowledgement of DMC-ODS Handbook Practice Guidelines and Provider Directory (docx)
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2021-02-09 |
209b Acknowledgement of DMC-ODS Handbook Practice Guidelines and Provider Directory (pdf)
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2021-02-09 |
210a Instructions SUD Program Admission Checklist 6-27-18 (pdf)
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2018-07-06 |
210b SUD Program Admission Checklist (pdf)
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Revised October 2021 |
2021-11-02 |
300 Section 3 Detail 7-3-18 (pdf)
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2018-07-06 |
301a Instruction Justification for Continuing Services 05-01-2020 (pdf)
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Revised May 2020 |
2020-05-14 |
301c Justification for Continuing Services Form Fill 07-01-19 (pdf)
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2019-09-03 |
301c Justification for Continuing Services Hard Copy 07-01-19 (pdf)
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2019-07-26 |
302a Instruction Alcohol and Drug Hx 4-12-17 (pdf)
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2017-05-01 |
302b Alcohol and Drug History Form 4-12-17 (pdf)
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2017-05-01 |
303a Instruction ASI-YAI 01-11-19 (pdf)
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2019-02-11 |
303c ASI Lite (pdf)
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2017-04-27 |
303d YAI (pdf)
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2018-09-11 |
304a Instruction Co-occurring Form 4-12-17 (pdf)
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2017-05-01 |
304b Co-occurring Screening Form 4-12-17 (pdf)
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2017-04-27 |
304c Form Fill Co-occurring Screening Form 4-12-17 (doc)
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2017-04-27 |
305a-1 Instruction Risk Assessment and Safety Management Plan 06-06-19 (pdf)
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Revised 06-06-19 |
2019-07-22 |
305a-2 Risk Assessment and Safety Management Plan 06-06-19 (pdf)
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2019-07-22 |
305b-1 Instruction High Risk Assessment 06-06-19 (pdf)
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Revised 06-06-19 |
2019-07-22 |
305b-2 High Risk Assessment 06-06-19 (pdf)
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2019-07-22 |
306a Instructions Level of Care Recommendation (pdf)
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Revised December 2020 |
2020-12-23 |
306b Level of Care Recommendation (pdf)
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Revised December 2020 |
2020-12-23 |
307a Instructions Assessment Summary 01-11-19 (pdf)
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2019-02-11 |
307b Assessment Summary 06-26-18 (pdf)
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2018-07-06 |
307c Assessment Summary Form Fill 06-26-18 (pdf)
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2018-07-06 |
308a Instructions Diagnosis Determination Note 01-11-19 (pdf)
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2019-02-11 |
308b Dx Determination Note Hard Copy 07-01-19 (pdf)
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2019-07-26 |
308c Dx Determination Note Form Fill 07-01-19 (pdf)
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2019-09-03 |
400 Section 4 Detail 01-14-19 (pdf)
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2019-02-11 |
401a Instruction WM Observation Log 11-26-19 (pdf)
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2019-12-02 |
401b Withdrawal Observation Log 11-21-19 (pdf)
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2019-12-02 |
402a Instruction Centrally Stored Medication & Destruction Record 4-12-17 (pdf)
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2018-07-06 |
402b Centrally Stored Medication and Destruction Record (pdf)
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2017-04-27 |
403a Instruction Health Questionnaire Form 9-30-18 (pdf)
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2018-10-11 |
403b Health Questionnaire 09-25-18 (pdf)
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2018-10-11 |
404a Instruction TB questionnaire 01-11-19 (pdf)
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2019-02-11 |
404b TB screening form 4-12-17 (pdf)
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2017-05-01 |
406 Physician Direction Form 4-12-17 (pdf)
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2017-05-01 |
406a Instruction Physician Direction form 01-09-19 (pdf)
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2019-02-11 |
407 MD Recomendation to client 4-12-17 (pdf)
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2017-05-01 |
407a Placement - Physical Exam Results 05-01-2020 (pdf)
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Revised May 2020 |
2020-05-14 |
408 Placement - Proof of Pregnancy 01-11-19 (pdf)
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2019-02-11 |
500 Section 5 Detail 01-14-19 (pdf)
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2019-02-11 |
501a Instructions Initial Treatment Plan 05-01-2020 (pdf)
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Revised May 2020 |
2020-05-14 |
501b Initial Treatment Plan 05-01-2020 (pdf)
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Revised May 2020 |
2020-05-14 |
502a Instructions Updated Treatment Plan (pdf)
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Revised October 2021 |
2021-11-03 |
502b Updated Treatment Plan 05-01-2020 (pdf)
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Revised May 2020 |
2020-05-14 |
503a Instructions Treatment Plan Addendum 01-11-19 (pdf)
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2019-02-11 |
503b Treatment Plan Addendum (pdf)
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Revised 08/06/2018 |
2020-01-06 |
504a Instructions Recovery Plan (pdf)
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2019-03-18 |
504b Recovery Plan Worksheet (pdf)
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2019-03-18 |
505a Instructions Treatment Effectiveness Assessment 01-09-19 (pdf)
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2019-02-11 |
505b Treatment Effectiveness Assessment 01-09-19 (pdf)
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2019-02-11 |
506a Instructions WM TX Plan for DMC-ODS (pdf)
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Revised October 2021 |
2021-11-03 |
506b WM Tx Plan for DMC‐ODS 05‐ 01‐2020 (pdf)
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Revised May 2020 |
2020-05-14 |
600 Section 6 Detail 01-15-19 (pdf)
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2019-02-11 |
601a Instructions SUD Treatment Progress Note (pdf)
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Revised October 2021 |
2021-11-03 |
601b SUD Treatment Progress Note - Hard Copy (pdf)
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Revised October 2021 |
2021-11-03 |
601c SUD Treatment Progress Note - Form Fill (pdf)
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Revised October 2021 |
2021-11-03 |
602a-1 Instructions for Residential Weekly Progress Note - Narrative 01-24-19 (pdf)
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2019-02-11 |
602a-2 Weekly Progress Note Residential - Narrative - Hard Copy 6-27-18 (pdf)
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2018-07-06 |
602a-3 Weekly Progress Note Residential - Narrative - Form Fill 6-27-18 (pdf)
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2018-07-06 |
602b-1 Instructions for Residential Weekly Progress Note - Services 01-24-19 (pdf)
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2019-02-11 |
602b-2 Residential Weekly Progress Note - Services 12-01-2020 (pdf)
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Revised December 2020 |
2021-01-28 |
603a Instructions Residential WM Daily Progress Note 10-5-18 (pdf)
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2018-10-11 |
603b Residential WM Daily Progress Note Hard Copy 12-01-2020 (pdf)
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Revised December 2020 |
2020-12-23 |
603c Residential WM Daily Progress Note Form Fill (pdf)
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Revised December 2020 |
2020-12-23 |
604a Instructions Outpatient Group Progress Note 07-01-19 (pdf)
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2019-10-10 |
604b Outpatient Group Progress Note Hard Copy 07-01-19 (pdf)
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2019-07-26 |
604c Outpatient Group Progress Note Form Fill 07-01-19 (pdf)
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2019-07-26 |
605a Instructions Other Progress Note (pdf)
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Revised December 2020 |
2020-12-23 |
605b Other Progress Note (pdf)
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Revised December 2020 |
2020-12-23 |
605c Other Progress Note - Form Fill 12-01-2020 (pdf)
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Revised December 2020 |
2021-01-28 |
700 Section 7 Detail 01-15-19 (pdf)
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2019-02-11 |
701a Instructions Discharge Summary (pdf)
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Revised October 2021 |
2021-11-03 |
701b Discharge Summary - Hard Copy (pdf)
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Revised October 2021 |
2021-11-03 |
701c Discharge Summary - Form Fill (pdf)
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Revised October 2021 |
2021-11-03 |
703 Placement - SanWITS Discharge Profile 01-14-19 (pdf)
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2019-02-11 |
704a Instruction Client Discharge Plan (pdf)
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Revised October 2021 |
2021-11-03 |
704b Client Discharge Plan - Hard Copy (pdf)
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Revised October 2021 |
2021-11-03 |
704c Client Discharge Plan - Form Fill (pdf)
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Revised October 2021 |
2021-11-03 |
800 Section 8 Detail 01-15-19 (pdf)
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2019-02-11 |
801a Instruction Drug Test and Results Log 01-11-19 (pdf)
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2019-02-11 |
801b Drug Test and Result Log Form (pdf)
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2017-05-01 |
802 placement Drug Test Results From Lab 4-12-17 (pdf)
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2017-05-01 |
803 placement Progress Reports (pdf)
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2017-05-01 |
805 placement Referral Source Documents (pdf)
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2017-05-01 |
806a FAX COVER SHEET FOR RSUD AUTH (docx)
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Revised 01/29/2020 |
2020-02-11 |
807 Placement - SanWITS Residential Authorization Printout (pdf)
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2019-02-11 |