Contract Provider Forms
Welcome to the Fresno County Mental Health Plan, we have provided the following links for your convenience.
If you have additional questions please feel free to contact a Utilization Review Specialist at (559) 600-4645
71188-fresno-county-mhp-assessment-2022.doc(DOC, 119KB)NEW
CALIFORNIA-INTEGRATED-PRACTICE-—-CHILD-AND-ADOLESCENT-NEEDS-AND-STRENGTHS-fillable-rev-250827.pdf(PDF, 306KB)
Clinical Face Sheet(DOC, 48KB)
Discharge Summary and Plan(DOCX, 55KB)- NEW
FCMHP-Statement-of-Deficiencies-and-Corrective-Action-Plan-2023-Form.docx(DOCX, 18KB)
FCMHP Language Assistance Taglines 2023.pdf(PDF, 863KB) - NEW
MH-Psychiatric-SMHS-Timeliness-Record-Paper-Form.docx(DOCX, 118KB)
MH-Non-Psychiatric-SMHS-Timeliness-Record-Paper-Form[78].docx(DOCX, 123KB)
NAR-ABD-Overturned-2025.docx(DOCX, 90KB)
NAR-ABD-Overturned-2025-Hmong.docx(DOCX, 91KB)
NAR-ABD-Overturned-2025-Spanish.docx(DOCX, 90KB)
NAR-ABD-Upheld-2025.docx(DOCX, 90KB)
NAR-ABD-Upheld-2025-Hmong.docx(DOCX, 91KB)
NAR-ABD-Upheld-2025-Spanish.docx(DOCX, 91KB)
NAR-Your-Rights-2025.docx(DOCX, 43KB)
NAR-Your-Rights-Spanish-2025.docx(DOCX, 43KB)
NAR-Your-Rights-Hmong-2025.docx(DOCX, 24KB)
NOABD-Authorizing-Delay-2025.docx(DOCX, 86KB)
NOABD-Authorization-Delay-Notice-Hmong.docx(DOCX, 458KB)
NOABD-Authorization-Delay-Notice-Spanish.docx(DOCX, 457KB)
NOABD-Delivery-System-2025.docx(DOCX, 89KB)
NOABD-Delivery-System-Hmong-2025.docx(DOCX, 89KB)
NOABD-Delivery-System-Spanish-2025.docx(DOCX, 88KB)
NOABD-Denial-Notice.docx(DOCX, 507KB)
NOABD-Denial-Notice-Hmong.docx(DOCX, 455KB)
NOABD-Denial-Notice-Spanish.docx(DOCX, 459KB)
NOABD-Financial-Liability-2025.docx(DOCX, 97KB)
NOABD-Financial-Liability-Hmong-2025.docx(DOCX, 97KB)
NOABD-Financial-Liability-Spanish-2025.docx(DOCX, 97KB)
NOABD-Grievance-Appeal-Resolution-Failure-to-resolve-timely-2025.docx(DOCX, 89KB)
NOABD-Grievance-Appeal-Resolution-Failure-to-resolve-timely.Hmong-2025.docx(DOCX, 91KB)
NOABD-Grievance-Appeal-Resolution-Failure-to-resolve-timely.Spanish-2025.docx(DOCX, 89KB)
NOABD-Modification-2025.docx(DOCX, 88KB)
NOABD-Modification-Hmong-2025.docx(DOCX, 88KB)
NOABD-Modification-Spanish-2025.docx(DOCX, 88KB)
NOABD-Payment-Denial-2025.docx(DOCX, 90KB)
NOABD-Payment-Denial-Hmong-2025.docx(DOCX, 87KB)
NOABD-Payment-Denial-Spanish-2025.docx(DOCX, 87KB)
NOABD-Termination-2025.docx(DOCX, 99KB)
NOABD-Termination-Hmong-2025.docx(DOCX, 96KB)
NOABD-Termination-Spanish-2025.docx(DOCX, 95KB)
NOABD-Timely-Access-2025.docx(DOCX, 87KB)
NOABD-Timely-Access-Hmong-2025.docx(DOCX, 90KB)
NOABD-Timely-Access-Spanish-2025.docx(DOCX, 96KB)
NOABD-Your-Rights-2025.docx(DOCX, 60KB)
NOABD-Your-Rights-2025-Spanish.docx(DOCX, 57KB)
NOABD-Your-Rights-2025-Hmong.docx(DOCX, 58KB)
Non-Discrimination-Notice-2025.docx(DOCX, 34KB)
Non-Discrimination-Notice-Hmong-2025.docx(DOCX, 43KB)
Non-Discrimination-Notice-Spanish-2025.docx(DOCX, 41KB)
Notice-of-Availability-Language-Tag-Lines-2025.pdf(PDF, 1MB)
Notice-of-Grievance-Resolution-2025.docx(DOCX, 98KB)
Notice-of-Grievance-Resolution-Hmong-2025.docx(DOCX, 99KB)
Notice-of-Grievance-Resolution-Spanish-2025.docx(DOCX, 98KB)
Pediatric Symptom Checklist (PSC-35-English)(PDF, 56KB)
Pediatric Symptom Checklist (PSC-35-Hmong)(PDF, 413KB)
Pediatric Symptom Checklist (PSC-35-Spanish)(PDF, 234KB)
PROBLEM-LIST-DBH-FINAL.pdf(PDF, 96KB)
Problem-List-User-Guide-FI.pdf(PDF, 627KB)
Transition-of-Care-Tool.pdf(PDF, 980KB)
Treatment Plan- Option No. 1(DOC, 98KB)
Treatment Plan- Option No. 2(PDF, 269KB)