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Policies and Procedures
 
 
 
Administration Policies
ADM - 0001  Policy and Procedure Overview
ADM – 0002  Policy and Procedures Glossary  
ADM – 0003  Administrator Responsibilities
 
Program Policies
PRG – 0001 Referrals for Dialectical Behavior Therapy  
PRG – 0002 On Site Counseling Services, DBT and Site Referral Process  
PRG – 0003 Continuity of Care for Incarcerated Consumers  
PRG – 1000 Assessment and Treatment Plan  
PRG – 1001 Consumer Fees/Co-Payment
PRG – 2000 Case Closure and Re-engagement Activities Required Prior to Disenrollment
PRG – 2001 Transfer of Care & Service Level Assessment/Assignment  
PRG – 3000 Referral to UPC or PRC-West
PRG – 3001 Inpatient Admission and Discharge Planning  
PRG – 4000 Title 36 Court Ordered Services
Rights Policies
RI – 0001  Consumer Rights
RI – 0002 Capacity to Give Informed Consent and Procedure for Requesting Special
Assistance for a SMI Consumer
RI – 0003 Grievance Procedure
RI – 0004 Consumer Contact Guidelines
RI – 0005 Abuse Recognition, Reporting and Care
RI – 0006 Member Right to Request Access to Protected Health Information (PHI) On Site RI – 0007
RI - 0007 Emergencies and Duty to Warn
Medications Policies
MED – 0001 Medication Orders, Administration and Documentation
MED – 0002 Communicating Primary Psychiatric Diagnosis
MED – 0003 Vital Signs Monitoring
MED – 0004 Monitoring Medications
MED – 0005 Communication of Medication Directives to Parties Involved in the Assistance
with Self-Administration of Medications
MED – 0006 Assistance in the Self-Administration of Medications
MED – 0007 Managing “Bubble Packs”
MED – 0008 Disposal of Discontinued or Expired Medications
MED – 0009 Lab Utilization
MED – 0010 Use of Fast-Acting Medications
Records Policies
REC – 0001 Verification
REC – 0002 Uses & Disclosures of PHI Requiring No Permission from Member
REC – 0003 Uses & Disclosures of PHI for Treatment, Payment, and Healthcare Operations.  
REC – 0004 Uses & Disclosures of PHI Requiring Prior Internal Approval
REC – 0005 Unauthorized Uses and Disclosures of PHI
REC – 0006 Oral and Written Transmission of PHI
REC – 0007 Minimum Necessary Uses and Disclosures of PHI
REC – 0008 Member Rights to Request an Accounting of Disclosures of PHI
REC – 0009 Limited Data Set and De-identification of PHI
REC – 0010 General Rules for Uses and Disclosures of PHI
REC – 0011 Consumer Records
REC – 0012 Authorization to Use and Disclose PHI
REC – 0013 Uses and Disclosures of PHI for Specialized Government Functions
Risk Management Policies
RM – 0001 Required Incident Reporting
RM – 0002 Clinic Safety and Welfare
RM – 0003 Adverse Drug Event and Medication Errors
RM – 0004 Exposure Control Plan
HR Policies
HR – 0001 Clinic Staff Qualifications
HR – 0002 Code of Ethical Conduct
HR – 0003 New Employee Orientation, Verification, and Training
HR – 0004 Credentialing of Clinical Staff
HR – 0005 Supervision of Nursing Staff
HR – 0006 Clinical Supervision
HR – 0007 Locum Tenen and Contract Doctor Coordination
HR – 0008 Maintaining Required Staffing Ratios and Requesting Additional Positions
Court Ordered Treatment Forms
Status Report Form (Title-XIX)
Status Report Form (Non-XIX SMI)
Status Report Letter
Amendment Letter to Presiding Judge (Non-XIX)
Police Mental Health Detention Information Sheet
Consumer’s Right to Judicial Review English
Consumer’s Right to Judicial Review Spanish
Psychiatric Report for Judicial Review
Request for Judicial Review
Annual Psychiatric Report PAD
Annual Psychiatric Report GD
Witness Information Form
Witness Statement Form-Blank
Certification of Release
Program Desktop SOPs
Inpatient Referral Transfer Process Chart
Special Assistance for Persons Determined to Have a Serious Mental Illness
Admission and Discharge Planning Chart
SMI Referral Process for Outpatient Services
Referral Request for Outpatient Services
SMI Packet Checklist
Single Case Agreements
ACT Admission/Transfer & Discharge
Inpatient Referral to an ACT Team
Adult Residential Treatment Requests
Community Housing Referrals
Transitional Living
Supervisory Care Homes
Vocational Rehabilitation
Coordination of Care
Crisis Management/Response
Crisis Procedure: Enrolled Adult Recipient GMH/SA, APNO and DCC chart
Grand Rounds
Services to Children and Youth
Unmet Needs
Individual Service Planning
Case Management and Clinical Team Services Plan
Civil Admission To and Discharge From the Arizona State Hospital
Decertification Process
Refund Policy for Direct Care Clinics (Spanish)
Clinica de Atencion Directa (DCC)/Centro de Atension Psiquiatrica de Urgencia (UPC) Politica
De Quejas (Reclamos)
Provider Referral Packets Requests Procedures
Referral Request (Attachment A)
Referral Request - Specific Program (Attachment B)
SMI Packet Checklist (Referral Request Attachment C)
SMI Packet Checklist Follow-Up for Missing Information (Attachment D)
Referral Packet Pick-Up Receipt (Attachment E)
ADHS/DBHS Referral for Behavioral Health Services (PM Form 3.3.1)
SMI Service Referral Tracking Log
Provider Referral Packet Flowchart
Rights Desktop SOPs
Adult PNO
Special Assistance for Persons Determined to Have a Serious Mental Illness
Child Abuse Reporting
Medication Desktop SOPs
Sample of Label Placement
Medication Refill Requests Procedure
Records Desktop SOPs
Medical Record Filing and Thinning
Member Right to Request Amendment of Protected Health Information (PHI) Workflow
Medical Record Forms Directory
Program Forms
PRG 0.01  Non-DBT Referral Guide for Clinical Teams
PRG 0.02 DBT Referral Guide for Clinical Teams
PRG 0.03 Dialectical Behavior Therapy Frequently Asked Questions
PRG 0.04 Outpatient Single Case Agreement Request Form
PRG 0.05 MIHS ACT Referral
PRG 0.06 Community Housing Application
PRG 0.07 Community Building Referral Request Form
PRG 0.08 Part E. Annual Behavioral Health Update and Review Summary
PRG 0.09 Part D. Behavioral Health Service Plan
PRG 0.10 Non-Title XIX/XXI Co-payment Assessment
PRG 0.11 Consumer Disenrollment Checklist Form
PRG 0.12 Transfer of Care Cover Sheet
PRG 0.16 Pre-Petition Screening Report
PRG 0.17 Inpatient Discharge Planning Checklist
PRG 0.18 Housing Application (ABC Homeless Programs)
PRG 0.19 Communication Document
PRG 0.20 Request for Information from PCP
PRG 0.21 Release from Evaluation
PRG 0.22 ADHS/DBHS Form MH-100 Application for Involuntary Evaluation
PRG 0.23 ADHS/DBHS Form MH-103 Application for Voluntary Evaluation
PRG 0.24 ADHS/DBHS Form MH-104 Application for Emergency Admission for Evaluation
PRG 0.25 ADHS/DBHS Form MH-105 Petition for Court-Ordered Evaluation
PRG 0.26 ADHS/DBHS Form MH-110 Petition for Court-Ordered Treatment (Gravely Disabled Person)
PRG 0.27 ADHS/DBHS Form MH-112 Affidavit
PRG 0.28 Request for Discharge from Detention Prior to Hearing for Court-Ordered Treatment
PRG 0.33 Site Referral to Urgent Psychiatric Care
PRG 0.34 Regional Behavioral Health Authority Informational Handbook
PRG 0.34sp Regional Behavioral Health Authority Informational Handbook (Spanish)
PRG 0.35 Review of Progress for Hospitalized Persons
PRG 0.36 Request for Special Assistance
Rights Forms
RI 0.01 Client Rights
RI 0.01sp Client Rights (Spanish)
RI 0.02 ADHS Form MH-211 Notice of Legal Rights for Persons with Serious Mental Illness
RI 0.02sp ACHS Form MH-211 Notice of Legal Rights for Persons with Serious Mental Illness (Spanish)
RI 0.03 Documentation of Informed Consent for Treatment
RI 0.04 Notification of Intent to Close
RI 0.05 Notice of Privacy Practices
RI 0.05sp Notice of Privacy Practices (Spanish)
RI 0.06 Consent to Treatment Form
RI 0.06sp Consent to Treatment Form (Spanish)
RI 0.07 Notice of Confidentiality of Alcohol and Drug Abuse Information
RI 0.07sp Notice of Confidentiality of Alcohol and Drug Abuse Information (Spanish)
RI 0.09 Consumer Complaint Form
RI 08.01 Notice of Action
RI 08.01sp Notice of Action (Spanish)
Medications Forms
MED 0.01 Signed Nurse’s Review and Approval of Forms
MED 0.02 Informed Consent for Psychotropic Medication Treatment
MED 0.03 MedWatch Voluntary Report of Adverse Events, Product Problems and Product Errors
MED 0.04 Daily Medication Administration Record
MED 0.05 Medication/Lab Flowsheet
MED 0.06 PCP Coordination Log
MED 0.07 Nursing Progress Note
MED 0.08 Vital Signs Record
MED 0.09 Communication of Medical Staff Directives Form
MED 0.10 Discussion with the Team Nurse
MED 0.11 Controlled Substance Record
MED 0.12 Medication Delivery Log
MED 0.13 Medication Disposal Log
MED 0.14 Stock Medication Disposal Log
MED 0.15 Stock Medication Order Form & Inventory Checklist
MED 0.16 Emergency Floor Stock Medication Reorder Form
MED 0.17 Special Treatment Plan – Referral for Involuntary Administration of Medications
MED 0.18 Pharmacy Medication Release Form
MED 0.19 Monthly Medication Inspection Form
MED 0.20 Medication Observation Form
MED 0.21 Request for Physician/Prescriber Coverage
MED 0.22 Lab Refrigerator Temperature Log
MED 0.23 Laboratory Test Request
Records Forms
REC 0.01 Summary of Request to Amend
REC 0.02 Denial of Request to Restrict the Use and Disclosure of Protected Health Information
REC 0.03 Disclosure of Protected Health Information (PHI) Report Form
Risk Management Forms
RM 0.00 Incident Report - short form
RM 0.01 Incident/Accident/Death Report Form
RM 0.02 Medication Incident Reporting Form
RM 0.03 Fire/Evacuation Drill
RM 0.04 Environmental Incident Report
RM 0.05 Federal Bloodborne Pathogens Standard
RM 0.06 Exposure Control Plan Annual Review
RM 0.07 Bloodborne Pathogen Exposure Incident Form
RM 0.08 Sharps Injury Log
RM 0.09 Concentra Locations
HR Forms
HR 0.01 Verification of Skills and Knowledge Interview Questions
HR 0.02 Assistance in Self-Administration of Medications Competency Exam
HR 0.03 Verification of Skills and Knowledge for Providing Clinical Supervision
HR 0.04 Clinical Supervision Log – Part One
HR 0.05 Clinical Supervision Log – Part Two – Clinical Case Review
HR 0.06 Administrative Supervision Log – Part Three
HR 0.07 Hepatitis B Vaccination Declination Form
HR 0.08 Clinical Case Review – Part One
HR 0.09 Clinical Case Review – Part Two
HR 0.10 Group Clinical Supervision Log
HR 0.11 Group Clinical Supervision Sign-In Sheet
HR 0.12 Individual Supervision Log
HR 0.13 Monthly Supervision Log
   
 

Process for Moving Services and Crisis Cleaning
 

MOVING & CRISIS CLEANING