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 Child and Adolescent Needs and Strengths Form (CANS-50-English Only)(PDF, 136KB) 

Clinical Face Sheet(DOC, 48KB)

MH_Non-Psychiatric-SMHS-Timeliness-Record-Paper-Form.docx(DOCX, 56KB)

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

NOABD-Authorization-Delay-Notice.docx(DOCX, 490KB)

NOABD-Authorization-Delay-Notice-Hmong.docx(DOCX, 458KB)

NOABD-Authorization-Delay-Notice-Spanish.docx(DOCX, 457KB)

NOABD-Delivery-System-Denial-Notice-Copy-2.docx(DOCX, 493KB)

NOABD-Delivery-System-Denial-Notice-Hmong-Copy-2.docx(DOCX, 462KB)

NOABD-Delivery-System-Denial-Notice-Spanish-Copy-2.docx(DOCX, 460KB)

NOABD-Denial-Notice.docx(DOCX, 507KB)

NOABD-Denial-Notice-Hmong.docx(DOCX, 455KB)

NOABD-Denial-Notice-Spanish.docx(DOCX, 459KB)

NOABD-Financial-Liability-Notice.docx(DOCX, 469KB)

NOABD-Financial-Liability-Notice-Hmong.docx(DOCX, 480KB)

NOABD-Financial-Liability-Notice-Spanish.docx(DOCX, 469KB)

NOABD-Modification-Notice.docx(DOCX, 459KB)

NOABD-Modification-Notice-Hmong.docx(DOCX, 466KB)

NOABD-Modification-Notice-Spanish.docx(DOCX, 459KB)

NOABD-Payment-Denial-Notice.docx(DOCX, 462KB)

NOABD-Payment-Denial-Notice-Hmong.docx(DOCX, 465KB)

NOABD-Payment-Denial-Notice-Spanish.docx(DOCX, 462KB)

NOABD-Termination-Notice-Direct-Service-Providers-Copy-2.docx(DOCX, 469KB)

NOABD-Termination-Notice-Direct-Service-Providers-Hmong-Copy-2.docx(DOCX, 466KB)

NOABD-Termination-Notice-Direct-Service-Providers-Spanish-Copy.docx(DOCX, 460KB)

NOABD-Termination-Notice-Managed-Care.docx(DOCX, 459KB)

NOABD-Termination-Notice-Managed-Care-Hmong.docx(DOCX, 461KB)

NOABD-Termination-Notice-Managed-Care-Spanish-Copy.docx(DOCX, 458KB)

NOABD-Timely-Access-Notice-Copy-2.docx(DOCX, 460KB)

NOABD-Timely-Access-Notice-Hmong-Copy-2.docx(DOCX, 463KB)

NOABD-Timely-Access-Notice-Spanish-Copy-2.docx(DOCX, 462KB)

NOABD “Your Rights” – English(PDF, 121KB)

NOABD “Your Rights” – Spanish(PDF, 120KB)

NOABD “Your Rights” – Hmong(PDF, 123KB)

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) 

Treatment Plan- Option No. 1(DOC, 98KB)

Treatment Plan- Option No. 2(PDF, 269KB)

 

If you have a Behavioral Health emergency
please call 9-1-1

For Access to Services or the Crisis Line,
1 800 654-3937

 CalHOPE Warm Line
1 833 317-HOPE(4673)

Central Valley Suicide Prevention Lifeline
1 800 273-8255