Clinical Documentation Forms

MHC*/MHA* Forms

MHC* Templates (Fillable)

Documents

• MHC* Forms

  • MHC(SC)-017 - Progress Note/Service Entry (06/18)
  • MHC018-7 - Children/Adolescent Medical Necessity Criteria (04/17)
  • MHC021-7 - Partnership Plan for Wellness | Spanish (3/14)
  • MHC022 - Discharge Summary (7/13)
  • MHC024 - Vocational Services Referral (3/10)
  • MHC028-4 - CSI Periodic Data Form (10/08)
  • MHC029 - Informed Consent for Psychotropic Medications | Spanish (11/14)
  • MHC(SC)-033 - Initial Clinical Assessment for Children (09/18)
  • MHC036-6 - Service Authorization (04/17)
  • MHC046-2 - Physician Orders & Medication Record (7/09)
  • MHC055-9 - Psychiatric Progress Note/Billing Form (04/17)
  • MHC058 - Referral for Therapeutic Behavioral Services (07/17)
  • MHC062-4 - WRAP Progress Note/Billing Form (04/17)
  • MHC(SC)-065 - Annual Clinical Update for Children (09/18)
  • MHC(SC)-096 - Registration | Spanish (08/18)
  • MHC(SC)-099A - Admission (06/18)
  • MHC(SC)-099B - Discharge (06/18)
  • MHC100 - Initial Clinical Assessment for Adults (04/17)
  • MHC102 - Adult Annual Clinical Assessment Update (04/17)
  • MHC105 - Psychiatric Partnership Plan | Spanish (7/17)
  • MHC(SC)-107 - Financial Information | Spanish (08/18)
  • MHC110 - Psychiatrist-RN TxPlan Child Form (12/12)
  • MHC112 - Katie-A Progress Note/Billing Form (04/17)
  • MHC113 - Initial Psychiatric Assessment Form (04/17)
  • MHC114 - Psychiatric Assessment Update Form (04/17)
  • MHC(SC)-118 - Child and Adolescent Needs Multisystem Assessment (09/18)
  • MHC(SC)-120 - Pediatric Symptom Checklist | Spanish (08/18)
  • MHC300 - ICC Eligibility Screening (08/17)
  • MHC301 - CFT Meeting Action Plan and Progress Summary (04/17)
  • MHC302 - IHBS Referral and Authorization (04/17)
  • MHC303 - IHBS 9 Month Treatment Review (04/17)
  • MHC304 - IHBS 12 Month Treatment Review (04/17)
  • MHC305 - ICC Referral (08/17)

  
  

  MHA* Forms

  • MHA002 - Change of Therapist/Doctor or Change of Diagnosis Form (4/17)
  • MHA(SC)-031 - MRN/Demographic Update Request (08/18)
  • MHA094 - CCMHP Insurance-Medicare Verification Notification Form (10/15)
  • MHA095 - CCMHP Insurance-Medicare Payment Notification Form (06/18)
  • MHA098 - Appeal Submission Checklist (06/18)
  • MHA31 - Request for Client Medical Record Number (10/15)

  
  

• MHC* Templates (Fillable)

  • MHC015T - TBS Monthly Service Authorization (04/18)
  • MHC(SC)-017T - Progress Note/Service Entry Template (06/18)
  • MHC021-7T - Partnership Plan for Wellness Template | Spanish (3/14)
  • MHC022T - Discharge Summary Template (7/13)
  • MHC023T - TBS Addendum Treatment Plan (04/18)
  • MHC025T - TBS Monthly Report (04/18)
  • MHC026T - TBS Termination Report (04/18)
  • MHC027T - TBS Preliminary Treatment Plan (04/18)
  • MHC(SC)-033T - Initial Clinical Assessment for Children (09/18)
  • MHC047T - TBS Final Treatment Plan (04/18)
  • MHC055-9T - Psychiatric Progress Note/Billing Form Template (04/17)
  • MHC058T - Referral for Therapeutic Behavioral Services (06/18)
  • MHC062-4T - WRAP Progress Note/Billing Form (04/17)
  • MHC(SC)-065T - Annual Clinical Update for Children (09/18)
  • MHC085T - TBS Provider Request for Payment & Authorization (04/18)
  • MHC(SC)-096 - Registration (08/18)
  • MHA098T - Appeal Submission Checklist (06/18)
  • MHC(SC)-099AT - Admission (06/18)
  • MHC(SC)-099BT - Discharge (06/18)
  • MHC100T - Initial Clinical Assessment Adult Template (04/17)
  • MHC102T - Adult Annual Clinical Assessment Update Template (4/17)
  • MHC105T - Psychiatric Partnership Plan Template | Spanish (7/17)
  • MHC(SC)-107 - Financial Information (08/18)
  • MHC110T - Psychiatrist-RN TxPlan Child (12/12)
  • MHC112T - Katie-A Progress Note/Billing Template (4/17)
  • MHC113T - Initial Psychiatric Assessment Template (4/17)
  • MHC114T - Psychiatric Assessment Update Template (4/17)
  • MHC(SC)-118T - Child and Adolescent Needs Multisystem Assessment (09/18)
  • MHC(SC)-120T - Pediatric Symptom Checklist | Spanish (08/18)
  • MHC300T - ICC Eligibility Screening (08/17)
  • MHC301T - CFT Meeting Action Plan and Progress Summary (04/17)
  • MHC302T - IHBS Referral and Authorization (04/17)
  • MHC303T - IHBS 9 Month Treatment Review (04/17)
  • MHC304T - IHBS 12 Month Treatment Review (04/17)
  • MHC305T - ICC Referral (08/17)

  
  

• Documents

  • DSM5 Update: 2017 | 2016
  • Q&A: Functional Assessment Tool for Children and Youth
  • CANS Manual
  • Clinical Documentation Manual 2017
  • CCMHP Documentation Training Manual 2014
  • DSM5 Crosswalk (1/1/18)
  • Notice of Privacy Practices | Spanish (11/16)