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)
CalMHSA-SMHS-Utilization-Review-Audit-Tool-Individual-Chart-Summary.pdf(PDF, 119KB)
CalMHSA-SMHS-Utilization-Review-Audit-Tool.xlsx(XLSX, 470KB)
Clinical Face Sheet(DOC, 48KB)
CSI-Standalone-Assessment-Form.docx(DOCX, 138KB)
IHBS Authorization Form - NEW(PDF, 237KB)
Discharge Summary and Plan(DOCX, 55KB)- NEW
FCMHP-Statement-of-Deficiencies-and-Corrective-Action-Plan-2023-Form.docx(DOCX, 18KB)
IHBS Authorization Form(PDF, 237KB)- NEW
IHBS Reauthorization Form update v2(PDF, 149KB)- NEW
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)
TBS Referral Form RVD 2.2021(PDF, 268KB)
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