DEPARTMENT OF MENTAL HEALTH (DMH) THERAPEUTIC BEHAVIORAL SERVICES (TBS

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DEPARTMENT OF MENTAL HEALTH (DMH) THERAPEUTIC BEHAVIORAL SERVICES (TBS Powered By Docstoc
					     FORM         RECIPIENT           TIMING          PURPOSE           ADDITIONAL
                                                                       INFORMATION


Notifications   Dee Taylor        Within 30 days     Comply with      DMH Letter No.
Initial Only    FAX: (916) 651-   of inception of    Emily Q.         99-03
                0493              the provision of   Final            Date of initial
                                  TBS to a           Judgment to      contact defined as
                                  beneficiary        provide          date the TBS
                                                     certain          worker/coach/aide
                                                     information      has contact with
                                                     to plaintiff’s   the client
                                                     attorneys.

                                                     Enable DMH
                                                     to track
                                                     utilization by
                                                     numbers,
                                                     need for
                                                     service,
                                                     class
                                                     membership,
                                                     residence,
                                                     etc
    FORM            RECIPIENT           TIMING          PURPOSE             ADDITIONAL
                                                                           INFORMATION


4th TBS           Dee Taylor        When the 4th       Informs DMH        DMH /MHP
Authorization     FAX: (916) 651-   Authorization is   of cases           Contract ,Exhibit
Summary. The      0493              approved by        where TBS          A, Attachment 1,
MPH may send                        the MHP            services will      ¶Y
subsequent                                             exceed the         This is not a
authorization                                          maximum            request for
(e.g. 5th, 6th,                                        days allowed       authorization from
etc.), but are                                         for the initial,   DMH. All
not required to                                        2nd and 3rd        authorization of
do so                                                  authorization      TBS is done by
                                                       periods            the MHP.
     FORM          RECIPIENT           TIMING         PURPOSE        ADDITIONAL
                                                                    INFORMATION


Certifications   Cynthia           When TBS will     Comply with    DMH Letter No.
                 Rutledge          not prevent       Emily Q. Final 01-03
                 FAX: (916) 651-   placement in a    Judgment to
                 0493              higher level of   provide
                                   care: RCL 12      certain
                                   (when the MHP     information to
                                   is involved in    plaintiff’s
                                   the placement);   attorneys.
                                   RCL 13, 14;
                                   Metropolitan or
                                   Napa state
                                   hospitals; or
                                   SNF/STP or
                                   MHRC that has
                                   been
                                   designated as
                                   an IMD.
  FORM     RECIPIENT          TIMING         PURPOSE        ADDITIONAL
                                                           INFORMATION


NOA      Cynthia           Within one       Comply with    DMH Letter No.
         Rutledge          month of being   Emily Q. Final 99-03
         FAX: (916) 651-   issued.          Judgment to
         0493                               provide
                                            certain
                                            information to
                                            plaintiff’s
                                            attorneys.
                Contact Information
Cynthia Rutledge                     Dee Taylor
Phone: (916) 651-9484                Phone: (916) 654-6933
FAX: (916) 651-0493                  FAX: (916) 651-0493
Email: cynthia.rutledge@dmh.ca.gov   Email: dee.taylor@dmh.ca.gov
Department of Mental Health          Department of Mental Health
1600 9th Street, Room 100            1600 9th Street, Room 100
Sacramento, California 95814         Sacramento, California 95814