Fee for Service Providers
This page is a resource for obtaining Medi-Cal documentation trainings, Specialty Mental Health Services (SMHS) treatment authorizations and other supportive provider materials
(800) 798-2254
Hours of Operation: Mon. - Fri. 8:00 a.m. - 5:00 p.m.
Provider Resource Materials
Select a category below to find additional materials.
Applications
New Provider Requirements
Beneficiary Materials
Electric versions below. Click HERE to access the order form.
English
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ACL Poster - English (pdf)
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Advance Directive - English (pdf)
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Advance Directive – English (pdf)
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Beneficiary Non-Discrimination Notice - ENGLISH (pdf)
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Grievance and Appeal Form - CCHEA Advocacy English (pdf)
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Grievance and Appeal Form - JFS Advocacy (pdf)
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Grievance and Appeal Process (pdf)
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Integrated MHP and DMC-ODC Member Handbook (pdf)
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Limited English Proficiency Poster - English (pdf)
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NOABD Delivery System Notice - ENGLISH (doc)
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NOABD Language Assistance Notice - ENGLISH (pdf)
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NOABD Your Rights Notice - ENGLISH (pdf)
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NPP Acknowledgement - English (pdf)
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Notice of Privacy Practices English (pdf)
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Open Payments Database Notice to Clients Display – ENGLISH (pdf)
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Physician Notice to Patients California Regulation – ENGLISH (pdf)
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Quick_Guide_BHS_Services_in_San_Diego_English_02-2025 (pdf)
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SD Grievance-Appeal POSTER English (pdf)
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SD Grievance-Appeal POSTER English LARGE FONT (pdf)
Arabic
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ACL Poster - Arabic (pdf)
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Advance Directive - Arabic (pdf)
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Beneficiary Non-Discrimination Notice - ARABIC (doc)
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Beneficiary Non-Discrimination Notice - ARABIC (pdf)
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Full Guide - Arabic (pdf)
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Grievance Appeal Brochure - Arabic (pdf)
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Grievance and Appeal Form - CCHEA Advocacy - Arabic (pdf)
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Grievance and Appeal Form - JFS Advocacy - Arabic (pdf)
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Limited English Proficiency Poster - Arabic (pdf)
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NOABD Delivery System Notice - ARABIC (doc)
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NOABD Your Rights Notice - ARABIC (pdf)
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NPP Acknowledgement - Arabic (pdf)
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Notice of Privacy Practices - Arabic (pdf)
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Quick_Guide_BHS_Services_in_San_Diego_Arabic_02-2025 (pdf)
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SD Grievance-Appeal POSTER Arabic (pdf)
Chinese
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NOABD_Your_Rights_Notice_-_Chinese.docx
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NOABD_Your_Rights_Notice_-_Chinese.pdf
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ACL Poster - Traditional Chinese (pdf)
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Advance Directive – Chinese (Traditional) (pdf)
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Grievance and Appeal Form – CCHEA OP Advocacy 6-28-18 Chinese (docx)
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Grievance and Appeal Form – JFS Advocacy 08-20-21 - Chinese (docx)
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NPP Acknowledgement Chinese (pdf)
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Notice of Privacy Practices – Chinese (pdf)
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Quick_Guide_BHS_Services_in_San_Diego_Chinese Traditional_02-2025 (pdf)
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SD Grievance - Appeal Brochure - Chinese (pdf)
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SD Grievance-Appeal POSTER Chinese (pdf)
Farsi
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ACL Poster - Dari (pdf)
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ACL Poster - Farsi (pdf)
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Advance Directive - Dari (pdf)
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Advance Directive Farsi (pdf)
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Beneficiary Non-Discrimination Notice - FARSI (doc)
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Beneficiary Non-Discrimination Notice - FARSI (pdf)
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Full Guide Farsi 2019 (pdf)
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Grievance and Appeal Form - CCHEA Advocacy - Farsi (docx)
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Grievance and Appeal Form - JFS Advocacy - Farsi (docx)
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Grievance-Appeal Brochure Farsi (pdf)
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Limited English Proficiency Poster - Farsi (pdf)
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NOABD Delivery System Notice - FARSI (doc)
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NOABD Your Rights Notice - FARSI (pdf)
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NPP Acknowledgement - Farsi (pdf)
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NPP Acknowledgement Dari (pdf)
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Notice of Privacy Practice - Dari (pdf)
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Notice of Privacy Practices - Farsi (pdf)
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Quick_Guide_BHS_Services_in_San_Diego_Persian_(Dari_Farsi)_02-2025 (pdf)
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SD Grievance-Appeal POSTER Farsi (pdf)
Korean
- NOABD_Your_Rights_Notice_-_Korean.pdf
- NOABD_Your_Rights_Notice_-_Korean.docx
- ACL Poster - Korean (pdf)
- Advance Directive - Korean (pdf)
- Grievance and Appeal Form – CCHEA OP Advocacy 6-28-18 Korean (docx)
- Grievance and Appeal Form – JFS Advocacy 08-20-21 - Korean (docx)
- NPP Acknowledgement Korean (pdf)
- Notice of Privacy Practices - Korean (pdf)
- Quick_Guide_BHS_Services_in_San_Diego_Korean_02-2025 (pdf)
- SD Grievance - Appeal Brochure - Korean (pdf)
- SD Grievance-Appeal POSTER Korean (pdf)
Somali
- NOABD_Your_Rights_Notice_-_Somali.pdf
- NOABD_Your_Rights_Notice_-_Somali.docx
- ACL Poster - Somali (pdf)
- Advance Directive – Somali (pdf)
- Grievance and Appeal Form – CCHEA OP Advocacy 6-28-18 Somali (docx)
- Grievance and Appeal Form – JFS Advocacy 08-20-21 - Somali (docx)
- NPP Acknowledgement Somali (pdf)
- Notice of Privacy Practices – Somali (pdf)
- Quick_Guide_BHS_Services_in_San_Diego_Somali_02-2025 (pdf)
- SD Grievance - Appeal Brochure - Somali (pdf)
- SD Grievance-Appeal POSTER Somali (pdf)
Spanish
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ACL Poster - Spanish (pdf)
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Advance Directive - Spanish (pdf)
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Beneficiary Non-Discrimination Notice - SPANISH (doc)
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Full Guide Spanish 2019 (pdf)
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Grievance - Appeal Brochure - Spanish (pdf)
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Grievance and Appeal Form - CCHEA Advocacy - Spanish (pdf)
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Grievance and Appeal Form - JFS Advocacy - Spanish (pdf)
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Limited English Proficiency Poster - Spanish (pdf)
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NOABD Delivery System Notice - SPANISH (doc)
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NOABD Your Rights Notice - SPANISH (pdf)
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NPP Acknowledgement - Spanish (pdf)
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Notice of Privacy Practices - Spanish (pdf)
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Quick_Guide_BHS_Services_in_San_Diego_Spanish_02-2025 (pdf)
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SD Grievance-Appeal POSTER - Spanish (pdf)
Tagalog
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ACL Poster - Tagalog (pdf)
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Advance Directive - Tagalog (pdf)
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Beneficiary Non-Discrimination Notice - TAGALOG (pdf)
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Beneficiary Non-Discrimination Notice - Tagalog (docx)
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Full Guide Tagalog 2019 (pdf)
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Grievance - Appeal Brochure - Tagalog (pdf)
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Grievance and Appeal Form - CCHEA Advocacy - Tagalog (pdf)
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Grievance and Appeal Form - JFS Advocacy - Tagalog (pdf)
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Limited English Proficiency Poster - Tagalog (pdf)
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NOABD Delivery System Notice - TAGALOG (doc)
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NOABD Your Rights Notice - TAGALOG (pdf)
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NPP Acknowledgement - Tagalog (pdf)
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Notice of Privacy Practices - Tagalog (pdf)
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Quick_Guide_BHS_Services_in_San_Diego_Tagalog_02-2025 (pdf)
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SD Grievance-Appeal POSTER Tagalog (pdf)
Vietnamese
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ACL Poster - Vietnamese (pdf)
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Advance Directive - Vietnamese (pdf)
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Beneficiary Non-Discrimination Notice - VIETNAMESE (doc)
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Beneficiary Non-Discrimination Notice - VIETNAMESE (pdf)
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Full Guide Vietnamese 2019 (pdf)
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Grievance - Appeal Brochure - Vietnamese (pdf)
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Grievance and Appeal Form - CCHEA Advocacy - Vietnamese (pdf)
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Grievance and Appeal Form - JFS Advocacy - Vietnamese (pdf)
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Limited English Proficiency Poster - Vietnamese (pdf)
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NOABD Delivery System Notice - VIETNAMESE (doc)
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NOABD Your Rights Notice - Vietnamese (pdf)
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NPP Acknowledgement - Vietnamese (pdf)
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Notice of Privacy Practices - Vietnamese (pdf)
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Quick_Guide_BHS_Services_in_San_Diego_Vietnamese_02-2025 (pdf)
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SD Grievance-Appeal POSTER Vietnamese (pdf)
CANS/PSC
Claims
Communications & Updates
2022 Communication/Updates
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CPT Codes 90846 and 99201 REMOVED from Fee Schedule (pdf)
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CalAIM Changes to Medical Necessity, Diagnosis & Reasons for Recoupment (pdf)
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Documentation Requirement Updates - Psychotherapy (pdf)
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Documentation Requirement Updates – Medication Services (pdf)
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False Claims Act Requirement 2022 (pdf)
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HSD Pharmacy Benefit Quick Guide (pdf)
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Mandatory E-Prescriptions (pdf)
2021 Communication/Updates
Archived Communication/Updates
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Microsoft Word - Optum Response to Presumptive Transfer Inquiries in SD -3.9.18
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Mild-Moderate-Severe FAQs (pdf)
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Outpatient Authorizations for Continuing Services during COVID-19 (pdf)
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Telephone Telehealth Approved Notification (pdf)
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Therapeutic Behavioral Services Prior Authorization Request & Referral Process (pdf)
Compliance
Manuals
Provider Newsletter
Provider Services
Provider Services
Resources to Assist & Inform Medi-Cal Members' Health Care Choices
Review - Inpatient
Review - Medication Quality Assurance
Review - Outpatient
SMHS Authorization Requests
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Ancillary Specialty Mental Health Services Request (docx)
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Demographic Form Fill (pdf)
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ECT_Authorization_Request_Form 6.1.2025 (pdf)
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FFS Medi-Cal Psychological Testing Request (docx)
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Interpreter Services Request Form (pdf)
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MFT Eligibility Verification Form (pdf)
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OAR Medication Services 4.16.25 (docx)
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OAR Medication Services 4.16.25 (pdf)
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OAR Psychotherapy 4.16.25 (docx)
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OAR Psychotherapy 4.16.25 (pdf)
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SMHS Psych Testing Criteria.2025 (pdf)
Templates and Examples
For Prescribers Only Templates
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Esketamine Progress Note (docx)
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Esketamine Progress Note (pdf)
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Informed Consent for Psychotropic Medication (docx)
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Informed Consent for Psychotropic Medication (pdf)
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Injectable Progress Note (docx)
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Injectable Progress Note (pdf)
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Medication Management Progress Note (docx)
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Medication Management Progress Note (pdf)
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Medication Management and Psychotherapy Note (docx)
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Medication Management and Psychotherapy Note (pdf)
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Psychotropic Medication Informed Consent Guide (docx)
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Psychotropic Medication Informed Consent Guide (pdf)
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TMS Progress Note (docx)
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TMS Progress Note (pdf)
Inpatient Authorization Requests
- IP MH and SB43 Fax Cover Sheet Effective 04.22.25 (pdf)
- Optum Notification - Hospitals Prospective Review - Effective 04/03/2023 (pdf)
- San Diego MH Inpatient Concurrent Review Authorization Process (pdf)
- SB43 CDRH Auth Req Process 2.19.25 (pdf)
- SB43 Optum to Hospital Partners IP BHU Auth Req Process Effective 2.3.25 (pdf)