Fee for Service Providers

This page is utilized by Fee For Service MediCal Providers to obtain documentation related to participation on the MediCal panel and continued authorizations for treatment.

Applications

Name Description Date
* BHETA - Acessing an ELEARNING (pdf)
2018-01-16
* BHETA - How to Print Certificate (pdf)
2018-01-16
* BHETA Acct Creation Instructions (pdf)
2017-11-29
* Form W-9 (Rev. December 2014)
Request for Taxpayer Identification Number and Certification 2017-11-02
* Instructions and FAQs Credentailing and Contracting (docx)
2017-12-13
* Medi-Cal Provider Specialty Addition Application (docx)
2018-02-09
* New Provider Medi-Cal Application (docx)
2018-02-15
* New Provider Medi-Cal and TERM Application (docx)
2018-01-30
* Paneled Medi-Cal Provider-TERM Application (docx)
2018-01-30

Beneficiary Materials

Name Description Date
* Grievance Appeal Brochure - English (pdf)
2017-12-13
* Grievance Appeal Brochure - Arabic (pdf)
2017-12-13
* Grievance Appeal Brochure - Spanish (pdf)
2017-12-13
* Grievance Appeal Brochure - Tagalog (pdf)
2017-12-13
* Grievance Appeal Brochure - Vietnamese (pdf)
2017-12-13
* ACL Poster.pdf
2016-10-12
* Grievance and Appeal Form-JFS Advocacy Arabic 1-15-16.pdf
2018-05-10
* Grievance and Appeal Form-JFS Advocacy Spanish 1-15-16.pdf
2018-05-10
* Grievance and Appeal Form-JFS Advocacy Tagalog 1-15-16.pdf
2018-05-10
* Grievance and Appeal Form-CCHEA Advocacy Vietnamese 1-15-16.pdf
2018-05-10
* Grievance and Appeal Form-CCHEA Advocacy English 1-15-16.pdf
2018-05-10
* Grievance and Appeal Form-CCHEA Advocacy Arabic 1-15-16.pdf
2018-05-10
* Grievance and Appeal Form-CCHEA Advocacy Tagalog 1-15-16.pdf
2018-05-10
* Grievance and Appeal Form-JFS Advocacy Vietnamese 1-15-16.pdf
2018-05-10
* Grievance and Appeal Form-JFS Advocacy English 1-15-16.pdf
2018-05-10
* Grievance and Appeal Form-CCHEA Advocacy Spanish 1-15-16.pdf
2018-05-10
* Recovery Brochure Spanish 09-11rev.pdf
2018-05-10
* Recovery Brochure English 8-5-13.pdf
2018-05-10
* NoticeofPrivacyPractices Vietnamese 12-16-14.pdf
2018-05-10
* NoticeofPrivacyPractices Tagalog 12-16-14.pdf
2018-05-10
* NoticeofPrivacyPractices Spanish 12-16-14.pdf
2018-05-10
* NoticeofPrivacyPractices English 12-16-14.pdf
2018-05-10
* NoticeofPrivacyPractices Arabic 12-16-14.pdf
2018-05-10
* LimitedEnglishProficiencyPoster Vietnamese.pdf
2018-05-10
* LimitedEnglishProficiencyPoster Spanish.pdf
2018-05-10
* LimitedEnglishProficiencyPoster English.pdf
2018-05-10
* LimitedEnglishProficiencyPoster Arabic 03-17-05.pdf
2018-05-10
* GrievanceAndAppealPoster Vietnamese 04-2012.pdf
Image 2018-05-10
* GrievanceAndAppealPoster Tagalog.pdf
Image 2018-05-10
* GrievanceAndAppealPoster English.pdf
Image 2018-05-10
* GrievanceAndAppealPoster Arabic.pdf
Image 2018-05-10
* County of San Diego Guide to Medi-Cal Mental Health Services - Vietnamese.pdf
2016-10-12
* County of San Diego Guide to Medi-Cal Mental Health Services - English.pdf
2016-10-12
* County of San Diego Guide to Medi-Cal Mental Health Services - Spanish.pdf
2016-10-12
* County of San Diego Guide to Medi-Cal Mental Health Services - Arabic.pdf
2016-10-12
* PUB325.pdf
2015-10-09
* PUB325.pdf
2015-10-09
* PUB 325 SP
2015-10-09
* PUB325.pdf
2015-10-09
* PUB325.pdf
2015-10-09
* Grievance and Appeal Form - JFS Advocacy 12-20-17 FARSI.docx
2017-12-22
* Grievance and Appeal Form - CCHEA Advocacy 12 20 17 FARSI.docx
2017-12-22
* Fee for Service Provider Directory – Spanish (PS-3 B) (xlsx)
2017-08-17
* PS-3 A and B
Outpatient Fee-for-Service Medi-Cal Provider Quarterly Directory Report (English/Spanish 2017-08-17
* Fee for Service Provider Directory – English (PS-3 A) (xlsx)
2017-08-17
* PS-3 A and B
Outpatient Fee-for-Service Medi-Cal Provider Quarterly Directory Report (English/Spanish 2017-08-17
* County of San Diego Guide to Medi-Cal Mental Health Services - Tagalog.pdf
2016-06-28
* Notice of Privacy Practices Acknowledgement Vietnamese 2014.docx
2018-05-10
* Notice of Privacy Practices Acknowledgement Tagalog 2014.docx
2018-05-10
* Notice of Privacy Practices Acknowledgement Spanish 2014.docx
2018-05-10
* Notice of Privacy Practices Acknowledgement English 2014.docx
2018-05-10
* Notice of Privacy Practices Acknowledgement Arabic 2014.docx
2018-05-10

Communications

Forms

Name Description Date
* Advance Health Care Directives.pdf
* Coordination of Care Release Form San Diego.doc
2015-10-09
* FINAL Coordination of Care Form Arabic.doc
* FINAL Coordination of Care Form Arabic.pdf
* FINAL Coordination of Care Form English.doc
* FINAL Coordination of Care Form English.pdf
* FINAL Coordination of Care Form Spanish.doc
* FINAL Coordination of Care Form Spanish.pdf
* FINAL Coordination of Care Form Tagalog.doc
* FINAL Coordination of Care Form Tagalog.pdf
2018-05-10
* FINAL Coordination of Care Form Viet.doc
2018-05-10
* FINAL Coordination of Care Form Viet.pdf
2018-05-10
* Interpreter Services Auth Form.pdf
2018-05-10
* Medi-Cal Behavioral Health Transition of Care Form.doc
2018-05-10
* Outpatient ECT Authorization Request.doc
2015-10-09
* BHS Serious Incident Report of Findings FINAL 01 01 15.doc
2015-11-05
* Sample Psych Testing Request Form 012016.pdf
2016-02-24
* Authorization To Use or Disclosed PHI Form.doc
2016-11-01
* BHS Serious Incident Report 12.10.15
2016-02-24
* Beneficiary Packet Materials Order Form (pdf)
2018-03-01
* Beneficiary Packet Materials Order Form.pdf
2016-10-12
* County of San Diego – Mental Health Services
2015-10-09
* DEMOGRAPHIC FORM FILL.docx
2016-11-02
* FORMS
2015-10-09
* Medi-Cal Psychological Testing Request Form
2016-02-29
* Microsoft Word - CARE PLAN INFORMED CONSENT PSYCHOTROPIC MEDICATION
2018-02-01
* Microsoft Word - Outpatient Authorization Request Form 9.28.16 Form Fill
2016-09-29
* Microsoft Word - Outpatient Authorization Request Form 9.28.16 Form Fill
2016-11-11
* NOA-A Arabic Rv 11 01 161.docx
2016-12-20
* NOA-A English.docx
2017-05-30
* NOA-A Spanish Rv 11 01 16.docx
2016-12-20
* NOA-A Tagalog Rv 11 01 16.docx
2016-12-20
* NOA-A Vietnamese.docx
2017-12-22
* OptumHealth Public Sector San Diego
2016-02-24
* Outpatient Authorization Request Form 9.28.16 Form Fill.docx
2016-09-29
* Public Sector
2015-10-09
* STATE OF CALIFORNIA--HEALTH AND WELFARE AGENCY
2016-12-20
* Template - Discharge Summary (docx)
2017-04-25
* Template - Intial Assessment (docx)
2017-04-25
* Template - Med Management Progress Note (docx)
2017-04-25
* Template - Progress Note (docx)
2017-04-25
* Template - Treatment Plan (docx)
2017-04-25

Manuals

Name Description Date
* FFS Provider Operations Handbook – Revised 04/30/2018 (pdf)
2018-05-01
* Microsoft Word - FFS Provider Operations Handbook 12.27.17
2017-12-27
* TABLE OF CONTENTS
2015-10-09

Quick Reference

Review

Name Description Date
* Enclosure 4 FY 17-18
2017-11-06
* Beneficiary Packet Materials Order Form (pdf)
2016-10-12
* Beneficiary Packet Materials Order Form (pdf)
2018-03-01
* Documentation Tip Sheet (pdf)
2016-09-15
* Inpatient Review Tool (pdf)
2017-08-07
* Record Keeping and Treatment Record Requirements (pdf)
2017-08-07
* Site Review Tool (pdf)
2018-02-22
* Treatment Record Review Tool (pdf)
2017-05-10