Department of Health: Comunity Based Case Management (CBCM)

North Shore Mental Health Forms

 Client Documentation

• NSMH CBCM Intake Assessment Form
• Authorization to Release/Obtain Confidential Information
• Clients Right Acknowledgement
• Consent to Treatment
• HIPPA Acknowledgement
• Client Insurance Information
• Individual Recovery Plan (pdf format)
• Individual Recovery Plan (word format)
• Progress Notes
• Transfer Discharge
• Transport Permission
• Childrens Crisis Plan

Billing Documentation

• CBCM Billing Clarifications Revised 4-05
• CBCM Billing Form Revised 9-06
• CBCM Psychiatric Billing Clarifications
• CBCM Psychiatric Billing Form

Administration Forms

• CBCM Form Checklist
• NSMH Supervision Form
• Case Review Supervision Form
• Vacation / Leave of Absence Form
• Client Satisfaction and Accessibility Survey
• Time Sheet
• NSMH Fax Cover Sheet

Adult Mental Health Division Documentation and Various Forms

Utilization Management (UM) Forms

• LOCUS / CAGE AID / MIDAS
• *Revised UM Forms will be available soon. In the meantime, UM forms can be found at the Wahiawa office.

Miscellaneous     

• AMHD Eligible Dx Codes
• AMHD Referral Form
• AMHD Referral Form Instructions
• Authorization for Use/Disclosure DOH
• CBI/CRF FORM
• CBI/CRF INSTRUCTIONS 
• Consumer Update/Increased Units
• CRF- Agreement For Repayment 
• Hospital Recovery Plan Review
• InterimHousing
• Crisis Plan
• Advance Mental Health Directive
• Bureau of Prisons NCIC Clearance

Emergency/Crisis Forms

• Application for Emergency Exam and Treatment/Oral Ex Parte 
• Request for Emergency Rx Form-DHS1149 

Consumer Sentinel Event/Incident Documentation

• Sentinel Event Incident Form
• Sentinel Event Immediate Notification Form 
• Sentinel Event 10 Day Report Form

Assessment Forms and Diagnostic Tools

• CageAid Screening Form
• MR Screening Form
• MR Screening Form Instructions
• Quality of Life Interview - Very brief
• Demographic - Admission

Community Based CM Forms

• Adult Mental Health Division - Service Authorization Request 
• Club House Application
• Helping Hands Rep Payee Referral
• Helping Hands Expedite SSA Request
• Helping Hands Rep Payee Check Request
• Hale Ipu Rep Payee Referral
• Hale Ipu Rep Payee Check Request
• Consumer Budget Form for Rep Payee (For HHH & Hale Ipu)
• The BUS- Bus Pass Application
• Po'ailani Intake Screening Application
• Po'ailani Psychiatric Assessment Form
• Po'ailani Physical Evaluation Form
• Helping Hands Hawaii Emergency Assistance Fund Application
   

Miscellaneous Forms

• DOH Authorization for Use of Disclosure of Protected Health Information (BLANK FORM)
   

Steadfast Forms (SHDC)

• Referral Form
• Consent to Release Information
• Certificate of Criminal History Form
• Certification of Homelessness
• Certification of Severe & Persistent Mental Illness