TCM
CMH
- Access to Services in an Emergency:
This document outlines emergency procedures for clients receiving services. It describes actions to take in various emergency situations (e.g., fire, gas leak, illness) and provides instructions on how to contact staff or call 911. It also includes signatures from both staff and clients acknowledging that they understand these emergency protocols.
- Acknowledgment of Receipt of HIPAA (General):
This form confirms that a client or their legal guardian has received a copy of the HIPAA Notice of Privacy Practices, which explains how protected health information (PHI) will be used and disclosed. It includes client, case manager, and legal guardian signatures and acknowledges that HIPAA policies may change periodically.
- Acknowledgment of Receipt of HIPAA (Community):
Similar to the general HIPAA acknowledgment but tailored for community-based services. Clients or legal guardians sign to confirm their receipt of the HIPAA Notice of Privacy Practices, explaining how their PHI will be used and their rights concerning it.
- Adult Certification (Mental Health Targeted Case Management):
This certification verifies that an adult meets the criteria for receiving Medicaid-funded mental health targeted case management. It requires documentation of mental health conditions, ongoing service needs, lack of natural support systems, and checks whether the individual is receiving duplicate services from another provider.
- Advance Directive Acknowledgment:
This document allows clients to specify preferences for mental health treatment in case they become unable to make decisions. Clients can name a mental health care agent to make decisions on their behalf. The form also acknowledges that an advance directive is not required for receiving services, and clients can provide a copy if they have one.
- Case Management Assessment:
This comprehensive assessment form collects detailed information about a client’s medical, psychiatric, social, and functional status. It helps case managers develop tailored service plans and includes sections on demographics, presenting problems, medication history, strengths/weaknesses, living arrangements, educational status, employment, and social support system.
- Case Management Assessment (Lite):
A simplified version of the full case management assessment form, gathering essential information such as client demographics, presenting problems, psychiatric history, current medications, and living arrangements. It covers current service needs and support systems to aid in developing a basic service plan.
- Authorization for Disclosure of Protected Health Information (PHI):
This consent form allows clients to authorize the release or request of their PHI for specific purposes, such as case management assessments, progress notes, or service coordination. The form requires the client’s signature and outlines the organizations or individuals involved in the PHI exchange, along with an expiration date for the authorization.
- Biopsychosocial Assessment (Community):
This document serves as a comprehensive assessment tool used to evaluate clients’ biological, psychological, and social factors impacting their health and functioning. It covers sections such as client information, family history, medical and psychiatric history, addictive behaviors, employment, education, and legal status, and strengths and weaknesses.
- Brief Behavioral Health Status Exam (Community):
This exam assesses a client’s current behavioral health status and determines treatment needs. Key elements include appearance and demeanor, risk assessments for suicide or harm, mental health symptoms (e.g., delusions, hallucinations), and a formal diagnosis based on DSM-V or ICD-10 codes.
- Business Associate Agreement:
This document outlines the legal relationship between a Covered Entity (e.g., CedrusMed) and a Business Associate under HIPAA regulations. It includes obligations regarding PHI protection, permitted uses and disclosures, and reporting of breaches. It also covers conditions under which the agreement can be terminated and how PHI will be returned or destroyed afterward.
- CFARS (Functional Assessment Rating Scale):
This document assesses the functioning of clients in mental health or substance abuse programs in Florida, evaluating 16 key areas. These include depression, anxiety, interpersonal relationships, activities of daily living, and risk factors related to harm (danger to self or others).
- Children’s Certification (Mental Health Targeted Case Management):
This form certifies that a child meets the criteria for receiving Medicaid-funded mental health case management. It verifies the child’s mental health disability, lack of natural support systems, and whether they are at risk of out-of-home placement. It ensures the child is not receiving duplicate case management services from other providers.
- Client Attendance Sheet (Community):
This form tracks client attendance for mental health services, including the client’s name, therapist information, session times, and both client and therapist signatures to verify attendance.
- Consent for Treatment:
This form provides legal consent for clients to receive mental health services. It includes authorization for treatment, a medical information release for PHI use, and a clause allowing clients to revoke consent at any time. Electronic signatures are also allowed.
- Consent for Treatment (Community):
Similar to the general consent for treatment form, but adapted for community services. It includes the client’s or guardian’s authorization, revocation clause, consent for sharing PHI, and approval for using electronic signatures.
- Consumer Rights Statement:
This document informs clients of their rights when receiving mental health services. Key rights include non-discrimination, participation in the creation and review of individualized service plans, privacy rights, and access to grievance procedures for reporting complaints.
- Coordination of Care Form:
This form is used to authorize or deny the exchange of information between the client’s mental health provider and their primary care physician. It captures the client’s consent and details of the involved parties to coordinate medical and mental health information.
- Discharge Summary Form:
This form documents a client’s discharge from mental health services. It includes client information, presenting problems, treatment summaries, reasons for discharge, and any referrals to other agencies for ongoing support.
- FARS (Functional Assessment Rating Scale):
This document assesses clients’ mental health functioning across various domains, such as depression, anxiety, daily living skills, and interpersonal relationships. It also assesses danger to self or others and cognitive performance.
- Food Safety Policy Statement:
This document outlines the provider’s policy regarding the distribution of food to clients. It includes a liability release that protects the provider from any adverse reactions a client might experience and ensures adherence to food safety guidelines.
- Foreign Language Acknowledgment:
This form certifies that a client or their legal guardian has had all relevant documents explained to them in their primary language. It includes a signature from both the client/guardian and case manager to confirm understanding and approval.
- Foreign Language Acknowledgment (Community):
Similar to the general foreign language acknowledgment, adapted for community settings. It ensures the client or guardian has received all necessary information in their primary language and signs relevant forms.
- HIPAA Business Associate Agreement:
This agreement ensures that a Business Associate complies with HIPAA regulations when handling PHI. It outlines obligations such as permitted uses and disclosures, breach reporting, and termination of the agreement if the PHI is mishandled.
- Case Management Intake Form:
This form collects essential client information during intake, including personal details, referral information, and medical/psychiatric diagnoses. It helps set the foundation for service planning and coordination.
- Mental Health Intake Form (Community):
Similar to the case management intake form but focused on mental health services. It includes sections on client details, insurance information, and any special accommodations or additional notes relevant to the intake process.
- Internal Referral Form:
This form facilitates the internal referral of a client within an organization, capturing key information such as the client’s name, diagnosis, and the assigned case manager.
- Medication Log:
This form tracks the medications prescribed to a client at the start of their treatment, listing all medications, dosages, start dates, and noting any allergies.
- No Duplication of TCM Services Acknowledgment:
This form confirms that the client is not receiving Targeted Case Management (TCM) services from another provider, preventing duplicate services that could lead to Medicaid fraud.
- No Duplication of Mental Health Services Acknowledgment (Community):
Similar to the TCM acknowledgment but focused on general mental health services, ensuring that the client does not receive duplicate services from another provider. - No-Harm Contract:
This document is a client agreement pledging not to engage in self-harm or suicidal attempts. It outlines actions the client should take if experiencing suicidal thoughts, such as contacting 911 or a crisis hotline.
- Photograph/Video Permission Form:
This form grants permission for a client’s photographs or videos to be used for identification or treatment purposes, ensuring they will not be used for commercial purposes.
- Pre-Admission Medication Log:
This document records all medications a client is taking before being admitted to a program, including both prescription and over-the-counter medications, along with any allergies.
- Clubhouse Progress Note:
This form tracks a client’s progress in a clubhouse setting, which focuses on psychosocial rehabilitation. It captures details like session times, behavior, mood, and the client’s progress toward goals.
- Progress Note (Clubhouse, Community):
This document tracks the client’s progress in a clubhouse setting for psychosocial rehabilitation. It records session details, client behavior and response, and progress evaluation (e.g., significant, moderate, minimal progress).
- Progress Note (Community):
This document logs client progress for community-based services, including session information, skills/interventions used, and an overall progress summary with notes on future care plans.
- Progress Note (Group Therapy, Community):
This document records group therapy sessions, including the client’s response, therapeutic techniques used, and progress made toward therapy goals.
- Progress Note (Individual Therapy, Community):
This form is used for documenting individual or family therapy sessions, capturing the client’s presentation, interventions used, and their progress toward therapy goals.
- Medication Management Progress Note (Community):
This form documents medication management sessions, tracking client details, current psychiatric medications, progress evaluation, and future care recommendations.
- Psychosocial Rehabilitation Progress Note (Community):
This document tracks a client’s psychosocial rehabilitation session, including session details, the client’s response, and techniques used to support progress.
- Psychiatric Evaluation (Community):
A comprehensive evaluation used for a psychiatric assessment, covering client demographics, presenting problems, mental status examination, diagnosis, and recommendations for further treatment.
