Substance Use Treatment Services - Forms
CalOMS Forms
- CALOMS Data Entry Form (html)
- CalOMS Administrative Discharge (Adult/Youth)-Fillable, pdf
- CalOMS Admission Questionnaire(Adult)- Fillable, pdf
- CalOMS Admission Questionnaire(Withdrawal Management)- Fillable, pdf
- CalOMS Admission Questionnaire(Youth)- Fillable, pdf
- CalOMS Discharge Questionnaire(Adult)-Fillable, pdf
- CalOMS Discharge Questionnaire(Withdrawal Management)-Fillable, pdf
- CalOMS Discharge Questionnaire(Youth)-Fillable, pdf
Credentialing Forms
Admission
- ALOC (v. 8.6.3)
- Admission Form
- Health Screening Questionnaire (HSQ) - Adobe PDF (Fillable), English
- Health Screening Questionnaire (HSQ) - Adobe PDF, Spanish
- Health Screening Questionnaire (HSQ) - Microsoft Word (Fillable), English
- Letter of Acknowledgement Receipt (SUTS Beneficiary Handbook) - Fillable
- Letter of Acknowledgement Receipt (SUTS Beneficiary Handbook) -Vietnamese
- Medical Necessity Diagnosis - Adobe PDF
- Medical Necessity Diagnosis - Microsoft Word (Fillable)
- Registration Form
- SUTS Assessment Summary - Adobe PDF
- SUTS Assessment Summary - Microsoft Word (Fillable)
- SUTS Integrated Behavioral Health Assessment
Client Feedback Survey Forms
Medication Assisted Treatment Forms
Prevention Forms
Provider Monthly Report Forms
Quarterly Peer Review Forms
Recovery Residences Forms
Release of Information
- Authorization for Use or Disclosure of Protected Health Information - (English), Dependency Wellness Court
- Authorization for Use or Disclosure of Protected Health Information - Addiction Medicine Treatment Attachment B (English), County
- Authorization for Use or Disclosure of Protected Health Information - CDCR(English), County
- Authorization for Use or Disclosure of Protected Health Information - General(Chinese), County
- Authorization for Use or Disclosure of Protected Health Information - General(English), BHSD, County
- Authorization for Use or Disclosure of Protected Health Information - General(English), County
- Authorization for Use or Disclosure of Protected Health Information - General(Spanish), County
- Authorization for Use or Disclosure of Protected Health Information - General(Tagalog), County
- Authorization for Use or Disclosure of Protected Health Information - General(Vietnamese), County
Treatment Services
- Client Status Report (CSR) - Microsoft Word (Fillable)
- Client Status Report (CSR) -pdf
- Continuing Justification Services - Extension - Adobe PDF
- Continuing Justification Services-Extension - Microsoft Word (Fillable)
- Discharge Plan - Microsoft Word (Fillable)
- Discharge Summary - Microsoft Word(Fillable)
- SUTS Recovery Service Plan (pdf)
- SUTS Recovery Service Plan - Microsoft Word (Fillable)
- SUTS Treatment Plan (Word)
Unicare Access Request Forms
Beneficiary Problem Resolution
- 1. Notice of Grievance Resolution (NGR) - English
- 1. Notice of Grievance Resolution (NGR) - Spanish
- 1. Notice of Grievance Resolution (NGR) -Vietnamese
- 10. Notice of Appeal Resolution - Determination Upheld (NAR) - English
- 10. Notice of Appeal Resolution - Determination Upheld (NAR)-Spanish
- 10. Notice of Appeal Resolution - Determination Upheld (NAR)-Vietnamese
- 12. Notice of Appeal Resolution - Determination Overturned (NAR)-English
- 12. Notice of Appeal Resolution - Determination Overturned (NAR)-Spanish
- 12. Notice of Appeal Resolution - Determination Overturned (NAR)-Vietnamese
- 15. Authorization Delay Notice (NOABD)-Spanish
- 15. Authorization Delay Notice (NOABD)-Vietnamese
- 2. Denial Notice (NOABD) - English
- 2. Denial Notice (NOABD)-Spanish
- 2. Denial Notice (NOABD)-Vietnamese
- 3. Payment Denial Notice (NOABD) - English
- 3. Payment Denial Notice (NOABD)-Spanish
- 3. Payment Denial Notice (NOABD)-Vietnamese
- 5. Modification Notice (NOABD) - English
- 5. Modification Notice (NOABD) -Spanish
- 5. Modification Notice (NOABD)-Vietnamese
- 6. Termination Notice (NOABD) - English
- 6. Termination Notice (NOABD) -Spanish
- 6. Termination Notice (NOABD) -Vietnamese
- 7. Timely Access (NOABD)-English
- 7. Timely Access (NOABD)-Spanish
- 7. Timely Access (NOABD)-Vietnamese
- 8.Financial Liability (NOABD)-English
- 8.Financial Liability (NOABD)-Spanish
- 8.Financial Liability (NOABD)-Vietnamese
- 9. NOABD “Your Rights” Attachment-English
- 9. NOABD “Your Rights” Attachment-Spanish
- 9. NOABD “Your Rights” Attachment-Vietnamese
- Appeal Extension Notification template(NOABD)-English
- Appeal Extension Notification template(NOABD)-Vietnamese
- Appeal Letter of Resolution Upheld (NAR)-English
- Appeal Letter of Resolution Upheld (NAR)-Spanish
- Appeal Letter of Resolution Upheld (NAR)-Vietnamese
- Beneficiary Grievance & Appeal Form-English
- Beneficiary Grievance & Appeal Form-Spanish
- Beneficiary Grievance & Appeal Form-Spanish-Vietnamese
- Grievance Appeal Extension Template (NOBD)-English
- Grievance Appeal Extension Template (NOBD)-Vietnamese
- Letter of Acknowledgement Receipt (Grievance & Appeal)-English
- Letter of Acknowledgement Receipt (Grievance & Appeal)-Spanish
- Letter of Acknowledgement Receipt (Grievance & Appeal)-Vietnamese
- 16. Grievance and Appeal Timely Resolution-English
- 16. Grievance and Appeal Timely Resolution-Spanish
- 16. Grievance and Appeal Timely Resolution-Vietnamese
- Appeal Letter of Resolution Overturned(NAR)-English
- Appeal Letter of Resolution Overturned(NAR)-Spanish
- Appeal Letter of Resolution Overturned(NAR)-Vietnamese
- Let Us Know What You Think
- We welcome your suggestions and ideas.