Substance Use Treatment Services
Data Support Division
Updated on 08/09/2016 LB

CLIENT ADMISSION FORM 

 Client ID:                  Client Name: 

 Admit Date:             Provider Name: 
 
DIAGNOSIS:
                                                  DSM 5 Dx Narrative                                                                                 ICD 10 Dx Code    
Rank 1:      

Rank 2:      

Rank 3:          
 
⇒ Selected Client – Client Information – Payors – Payor – Payor Information Tab.  If Self pay, skip to the Admission Reason.
 
Payors:          C50 MediCal                                     V50 VHP                                  Private Insurance (MAT Only)
             
Policy Holder:          Self                Family Member
 
Payor Name:          Payor ID No.1:     
                
Payor Rank:           Effective Date:      

Admission Reason:    111 = Substance Abuser is the only code that is to be used for Admission reason under Cost Center Location

Referral Type:                         

112: Self 119: School/College 130: State Drug Court Partnership (DCP)
113: Twelve Step Program 120: Medical 131: Comprehensive Drug Court Implementation (CDCI)
114: Social Services 121: Community Services 132: Dependency Court/Child Protective Services
115: Federal/State Criminal Justice 124: Public Health 136: Dependency Wellness Court (DWC)
116: Local/County Criminal Justice 125: Residential Care Facility 137: AB109 Post-Release Community Supervision
117: Family/Friend 127: Brochure/Flyer/Newspaper 203: DA Drug/Alcohol Program
118: Employer 128: Telephone/Directory 998: Other
  129: DUI/DWI

 

 ⇒ Client companies – Your Company – Episodes – Current Episode – Cost Center Locations – Cost Center – Profile of Cost Center Location -  Cost Center Identifier Tab

Cost Center Identifiers:
 111:  CWHA AOD Only  235:  DFCS (Division of FCS)  450:  Dependency Wellness Court (DWC)
 155:  DCP - Drug Court Realignment  260:  AB109 - CJ Realignment  480:  Measure A
175:  ASOC  265:  AB109 - CASU  500:  Transitional Age Youth (TAY) (YSOC)
 190:  CDCI - Drug Court Realignment  255:  Youth System of Care (YSOC)  510: CDCR
 
 Confidential Client Information: California Welfare and Institutions Code Section 5328 - 42 CFR and Title 42, Code of Federal Regulations, Part 2   
 

 
                                                
 
 
 
 
EARLY DROP-OUT CLIENT DISCHARGE INFORMATION
 
NOTE: The following information is ONLY entered for Early Dropout Clients.  No CalOMS required.
 

   Client #:                          Client Name: 

 

  Admit Date:                  Discharge Date:     

   

  Discharge Reason:
 

  Discharge Provider Name: 

 

  Discharge Location:  

 

  Discharge Cost Center: 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Confidential Client Information: California Welfare and Institutions Code Section 5328 - 42 CFR and Title 42, Code of Federal Regulations, Part 2