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Behavioral Health Staff: Forms & Policies

BHRS Policies

Pathways to Well-Being – Integrated Core Practice Model (ICPM) Provision of ICC, IHBS, TFC and Wraparound Services: 24-05
Admission Referral

Coming Soon: Policy 24-05 Pathways to Well-Being – Integrated Core Practice Model (ICPM) Provision of ICC, IHBS, TFC and Wraparound Services

Attachments
Attachment A: SMC ICC Eligibility Screening Form

Additional Reference Materials

BHRS Policies

Memorandum of Understanding between San Mateo Health Commission d/b/a Health Plan of San Mateo and Behavioral Health & Recovery Services
MOUs

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

BHRS Policies

Authorization of Adult Residential Services: 20-02
Admission Referral

Policy: 20-02 Authorization of Adult Residential Services

Attachments
Attachment A: Adult Residential Auth Form
Attachment B: Electronic Community Referral
Attachment C: Reauth Adult Residential Progress Summary

Original Policy Date: January 17, 2020
Amended: April 29, 2022, July 3, 2024
Attachment A: Technical Edit January 28, 2025
Attachment C: Technical Edit January 28, 2025
Supersedes: N/A

BHRS Policies

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

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

Attachments:

NEW POLICY: January 9, 2020
Attachments A, D, E: Technical Edit February 18, 2021 Attachment F: added February 18, 2021 

BHRS Policies

Consumer Problem Resolution & NOA: 19-01
Client Rights

Consumer Problem Resolution & NOA: 19-01 Policy 19-01

SUPERSEDES:  04-10 Notice of Action, 03-03 Consumer Problem Resolution System

New Policy June 2019, Technical edits and Translated attachments added, October 10, 2019; Technical Revision January 9, 2020
Attachment A: Technical Edit January 9, 2020; Amended May 4,
2023, Amended July 15, 2024

Attachment B:  TTechnical Edit March 12, 2021, Technical Edit and
name change March 14, 2021; Technical Edit September 24, 2021

BHRS Policies

Electronic Medical Record Security and Electronic Signatures: 17-01
HIPAA

Electronic Health Record (EHR) Security and Electronic Signatures: 17-01
Attachments:
BHRS Policies BHRS Doc Owner: Quality Management

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

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

BHRS Policies BHRS Doc Owner: Quality Management

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

Application for Services and Consent to Treatment: 96-15
Attachments:
Application for Services and Consent to Treatment: 96-15, Attachment A, Treatment Consent & Notice of Privacy Practices: English
Application for Services and Consent to Treatment: 96-15, Attachment A, Treatment Consent & Notice of Privacy Practices: Spanish
Application for Services and Consent to Treatment: 96-15, Attachment A, Treatment Consent & Notice of Privacy Practices: Tagalog
Application for Services and Consent to Treatment: 96-15, Attachment A, Treatment Consent & Notice of Privacy Practices: Tongan
Application for Services and Consent to Treatment: 96-15, Attachment, B. Minor Client Legal Status and Implications for Consent
Application for Services and Consent to Treatment: 96-15, Attachment, C. GGRS Clients Mentally Incapable of Giving Consent

BHRS Policies BHRS Doc Owner: Quality Management

Assaults on Clients – Suspected or Reported: 01-03
5150/Safety/Risk Policies

Policy: 01-03 Assaults on Clients – Suspected or Reported

Attachments:
Attachment A: Dependent Adult or Elder Abuse Reporting Agreement
Attachment B​: Child Abuse Reporting Agreement (for Employees)
Attachment C ​: Table – Mandated Reporting of Dependent Adult and Elder Abuse
Attachment D: Emergency and Mandated Phone Numbers for Reporting Dependent Adult/Elder Abuse
Attachment E: Police Phone Numbers for Reporting Purposes (Non-Emergency)
Attachment F: Link to Report of Suspected Dependent/Elder Abuse (SOC 341)
Attachment G: Mandated Reporting of Child Abuse
Attachment H: Emergency & Mandated Phone Numbers for Reporting Child Abuse
Attachment I: Link to Suspected Child Abuse Report (BCIA 8572)
Attachment J: Community Resources Crisis Lines
Attachment K: Instructions for Residential Care Facilities

BHRS Policies BHRS Doc Owner: Quality Management

Change of Clinician/Provider Request, including Charitable Choice: 98-01
Client Rights

Change of Clinician/Provider Request, including Charitable Choice: 98-01
Attachments:
Change of Clinician Request: 98-01, Attachment: A. Request for Change of Provider – English
Change of Clinician Request: 98-01, Attachment: B. Request for Change of Provider – Spanish
Change of Clinician Request: 98-01, Attachment: C. Request for Change of Provider – Tagalog
Change of Clinician Request: 98-01, Attachment: D. Request for Change of Provider – Chinese

BHRS Policies BHRS Doc Owner: Deputy Director Administration

Claims Processing Guidelines and Procedures: 07-04
Financial

Claims Processing Guidelines and Procedures: 07-04
Attachments:
Claims Processing Guidelines and Procedures: 07-04, Attachment: A. Explanation of Payment (EOP) Procedure
Claims Processing Guidelines and Procedures: 07-04, Attachment: B. Receipt and Processing of Claims from Providers
Claims Processing Guidelines and Procedures: 07-04, Attachment: C. Processing Payable MHP Claims
Claims Processing Guidelines and Procedures: 07-04, Attachment: D. Processing Denied MHP Claims
Claims Processing Guidelines and Procedures: 07-04, Attach E: Investigating Pended Claims before Final EOP Run


Claims Processing Guidelines and Procedures: 07-04, Attachment: G. Adjusting overpaid and underpaid claims
Claims Processing Guidelines and Procedures: 07-04, Attach I_Procedure for setting up providers and fees schedules in MSO
Claims Processing Guidelines and Procedures: 07-04, Attach J :Processing Payable MHP Claims 
Claims Processing Guidelines and Procedures: 07-04, Attach L: Procedure for Reimbursing Provider Claims for Telehealth and Phone
Claims Processing Guidelines and Procedures: 07-04, Attach M: Procedure for Identifying, Reporting, and Recovering Mental Health
Claims Processing Guidelines and Procedures: 07-04 , Attachment N: Procedure for System Maintenance

 

 

 

 

 

 

BHRS Policies BHRS Doc Owner: Deputy Director Administration

Client Insurance Information and Financial Participation: 03-12
Financial

Client Insurance Information and Financial Participation: 03-12
Attachments:
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: E. What You Need To Know about Payment, English
Attachment: E. What You Need To Know about Payment, Spanish
Attachment: D. Payer Financial Information
Attachment: F. Therapeutic Fee Adjustment Request forms
 

BHRS Policies BHRS Doc Owner: Quality Management

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

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

Attachments:
A. Declaration of Notice of Confidentiality

B. Authorization for Use or Disclosure of Health Information (Mental Health): English | Spanish | Chinese | Tagalog | Tongan | Russian

C. Authorization for the Verbal Release of Client Information (Mental Health):  English | Spanish | Chinese | Russian | Tagalog | Tongan

D. Excerpts from W&I Code |

E. Privacy Complaint Form

F. Exchange of Information: Principles and Definitions

G. Exchange of Information: Guide to Sharing

H. Authorization for Use or Disclosure of Protected Health Information (AOD Services): English | Spanish | Chinese | Russian | Tagalog | Tongan

BHRS Policies BHRS Doc Owner: Contract Manager

Contracts, Requests for Proposals (RFP), and Waivers of RFP Process: 97-06
Contracts

Contracts, Requests for Proposals (RFP), and Waivers of RFP Process: 97-06
Attachments:
Contracts, Requests for Proposals (RFP), and Waivers of RFP Process: 97-06, Attachment A- Contracting Methodologies
Contracts, Requests for Proposals (RFP), and Waivers of RFP Process: 97-06, Attachment B, Competitive Awards Procedure
Contracts, Requests for Proposals (RFP), and Waivers of RFP Process: 97-06, Attachment D, Public Notice

BHRS Policies BHRS Doc Owner: Quality Management

Disclosures of Protected Health Information (PHI) with Client Authorization: 03-06
HIPAA

Disclosures of Protected Health Information (PHI) with Client Authorization: 03-06

ATTACHMENTS:
See Policy 03-01: Confidentiality/Privacy of Protected Health Information (PHI)
• Attachment B: Authorization for Use or Disclosure of Protected Health Information
• Attachment C: Authorization for the Verbal Release of Client Information

BHRS Policies BHRS Doc Owner: Medical Director

Linkages between Outpatient Clinics and Psychiatric Emergency Services (PES) about Adult MH Clients Open to Region: 02-01
5150/Safety/Risk Policies

Linkages between Outpatient Clinics and Psychiatric Emergency Services (PES) about Adult MH Clients Open to Region: 02-01​
Attachments:
Attachment B. After Hours Phone Numbers​​
Linkages between Outpatient Clinics and Psychiatric Emergency Services (PES) about Adult MH Clients Open to Region: 02-01​​
Attachment C: Fax for PES & 3AB​​

BHRS Policies BHRS Doc Owner: Medical Director

Medication Room Management: 99-03
Medical Psychiatric

Medication Room Management: 99-03
Attachments:
Attachment: A. Controlled Substance/Emergency Supply Record
Attachment: E. Medication Room Inspection
Attachment: B. Medication Samples Log
Attachment: C. Sample Medication Label
Attachment: D. Record of Medication Storage and Removal for Destruction
Attachment: F. Protocol: Storage of Medications until Retrieval by Client
Attachment: G. Registration/Permit Application for Medical Waste Generation, Storage and Treatment
Attachment: H. Registration, Limited Quantity Hauling Exemption
Attachment: I. Limited Quantity Hauling Exemption Medical/Pharmaceutical Waste Tracking Document

BHRS Policies BHRS Doc Owner: Assistant Director

Credentialing and Re- Credentialing Providers: 19-08
Compliance

Credentialing and Re- Credentialing Providers Policy 19-08

Attachments: 

Original Policy Date: December 31, 2019,                                        Amended: Technical Edits January 9, 2020, November 5, 2020, June 26, 2023; Amended June 26, 2024
Attachment F: updated June 7, 2021
Attachment G: updated February 17, 2023
Attachment H: added June 26, 2023

Required Policies For New Staff to Review
BEHAVIORAL HEALTH CONFIDENTIALITY
CLINICAL STAFF ONLY
BHRS Policies BHRS Doc Owner: ODE

Services to Clients in Primary or Preferred Languages: 99-01
Clinical

99-01 Services to Clients in Primary or Preferred Languages: Policy

Attachments: 
Attachment A: Health System Policy A-25, Client’s Right to Language Services Notification Policy
Attachment B: Health System Policy A-26, No Use of Minors & Careful Use of Family for Interpretation Policy
Attachment C: Language Access Services Instructions
Attachment D: BHRS Progress Note

BHRS Policies BHRS Doc Owner: Deputy Director Adult BHRS Doc Owner: Deputy Director Youth

Standards of Care in an Integrated Behavioral Health System: 11-01
Clinical

Standards of Care in an Integrated Behavioral Health System: 11-01
Attachments:
Standards of Care in an Integrated Behavioral Health System: 11-01, Attachment B: Assessment and Integration of Spiritual Intere
Standards of Care in an Integrated Behavioral Health System: 11-01, Attachment A: Standards of Care for AOD Providers

BHRS Policies BHRS Doc Owner: Quality Management

Subpoenas to Release Records: 96-14
HIPAA

Policy: 96-14 Subpoenas to Release Records

Attachments: 
Attachment A: Subpoena Review Checklist
Attachment B : Sample Cover Letter for Forwarding Records per Appropriate Subpoena and Release
Attachment C : Sample Letter When No Release Accompanies Subpoena and All Documents Are Being Returned
Attachment D: Sample Letter for Returning Subpoena Previously Responded To

Additional Reference Materials
How to print an Avatar Chart for records release