SOC Provider Forms

Form Number & Description

  • Provider Initial Assessment Forms Bundle (ZIP) - Bundle of forms includes the Care 010e, Care 011, Care 015, Care 015a, Care 015e, Care 024, Care 036, Care 141e and HIPAA 05 
  • Care 008e (DOC) - Unified Service Plan (This form is to be downloaded and used as a Template) (Revised March 23, 2012)
  • Care 009e (DOC) - Request for Authorization / Treatment Plan Report (This form is to be downloaded and used as a Template) (Revised May 8, 2019)
  • Care 010e (DOC) - Data used to track Child treatment outcomes or treatment planning (This form is to be downloaded and used as a Template) (Revised April 17, 2013)
  • Care 011 (PDF) - Data used to track Adult treatment outcomes or treatment planning (Revised March 28, 2012)
  • Care 015 (PDF) - Required Biopsychosocial Assessment (Revised August 14, 2019)
  • Care 015e (DOC) - Required Biopsychosocial Assessment (This form is to be downloaded and used as a Template) (Revised August 26, 2019)
  • Care 015a (PDF) - Completed with the Care 15, contains CSI data and cultural services (Revised May 28, 2020)
  • Care 020 (PDF) - English version Appeal/Grievance Form used for both clients and providers to file a complaint (Revised March 7, 2019)
  • Care 020sp (PDF) - Spanish version Appeal/Grievance Form used for both clients and providers to file a complaint (Revised March 7, 2019)
  • Care 024 (PDF) - Contains required CSI data (Revised July 3, 2006)
  • Care 036 (DOC) - Consent to treat a minor (Revised April 30, 2009) (This form is to be downloaded and used as a Template)
  • Care 041e (DOC) - Systems of Care Progress Note (This form is to be downloaded and used as a Template) (Revised December 5, 2013)
  • Care 041ge (DOC) - Systems of Care Group Progress Note (This form is to be downloaded and used as a Template) (Revised September 5, 2008)
  • Care 053e (DOC) - Systems of Care ICD-10 Diagnosis Form (This form is to be downloaded and used as a Template) (Revised March 8, 2017)
  • Care 084 (PDF) - English version Request for Change of Service Provider - Second Opinion (Revised March 7, 2019)
  • Care 084sp (PDF) - Spanish version Request for Change of Service Provider - Second Opinion (Revised March 7, 2019)
  • Care 141e (DOC) - Child/Youth Biopsychosocial Assessment (This form is to be downloaded and used as a Template) (Revised August 14, 2019)
  • Care 207 (DOC) - Consent for Medication (This form is to be downloaded and used as a Template) (Revised September 18, 2019)
  • Care 441 (DOC) - Psychiatric Consultation Request Adult Medi-Cal Beneficiaries (This form is to be downloaded and used as a Template) (Revised November 18, 2010)
  • CLAS (DOC) - CLAS Standards Monitoring Mental Health Provider (This form is to be downloaded and used as a Template) (New January 31, 2017)
  • HIPAA 05 (PDF) - Required when communicating with others regarding a client (Revised October 2019)
  • CPT/HCPCS Codes (PDF) - Schedule of Contracted Rates Using Standardized CPT/HCPCS Codes
  • CMS-1500 (PDF) - This is only an example, the areas in yellow should be filled in on the CMS-1500 (Revised July 23, 2015)
  • Beneficiary Protection English and Spanish 2018 Update (ZIP) - Required Provider Posting Materials for Beneficiary Protection in English and Spanish (Revised May 2018)
  • DSM-IV-TR to ICD-9-CM Crosswalk (PDF) - DSM-IV-TR to ICD-9-CM Crosswalk, ICD-9-CM Fifth-Digit Descriptions and Criteria, and Global Assessment of Functioning (GAF) Scale
  • Provider Attestation (DOC) - Placer County provider attestation 1.31.17 (New January 26, 2017)
  • Provider Audit Tool (PDF) - Placer County Provider Audit Tool (Revised August 2019)
  • Tax Forms (PDF) - County of Placer required Tax Forms (Revised January 28, 2013)
  • Network Provider Manual (PDF) - Provider Manual (Revised October 16, 2015)