Provider Services

For accessibility issues, please contact Provider Services at 925-608-6790.

Directory

• Provider Directory

Provider Manual

• Provider Manual

Informing Materials (English/Spanish)

To request a printed copy of these materials for free, or in other formats, such as Braille or audio, call the Access Line at 1-888-678-7277. Requests will be processed within five (5) business days.

• Beneficiary Handbook
  The Beneficiary Handbook will be changing effective January 1, 2024.
  - Regular Print 12pt font (English | Spanish)
  - Large Print 18pt font (English | Spanish)
• MHA58 - Beneficiary Grievance Review Request Form
  - Regular Print 12pt font (English | Spanish)
  - Large Print 18pt font (English | Spanish)
• MHA56 - Appeal or Expedited Appeal Request Form
  - Regular Print 12pt font (English | Spanish)
  - Large Print 18pt font (English | Spanish)
• MHA54 - Beneficiary Request for Change of Provider Form
  - Regular Print 12pt font (English | Spanish)
  - Large Print 18pt font (English | Spanish)
• MHA52 - Beneficiary Suggestion Form
  - Regular Print 12pt font (English | Spanish)
  - Large Print 18pt font (English | Spanish)
• Advance Directive
  - Regular Print 12pt font (English | Spanish)
  - Large Print 18pt font (English | Spanish)
• Continuity of Care
  - Regular Print 12pt font (English | Spanish)
  - Large Print 18pt font (English | Spanish)

Posters (English/Spanish)

• Beneficiary Rights:
  - Letter size (English | Spanish)
  - Ledger size (English | Spanish)
  
• Grievance/Change of Provider/Appeal:
  - Letter size (English | Spanish)
  - Ledger size (English | Spanish)
  
• Informing Materials poster:
  - Letter size (English | Spanish)
  - Legal size (English | Spanish)
  
• Language Assistance:
  - Letter size
  - Ledger size
  

Credentialing Forms

• MHA12 - ShareCare ID Request Form (Required for all providers)
• MHA22 - Credentialing/Privileging Form (Required for all providers)
• MHA22c - SSN Consent Form (Required for all providers)
• MHA22g - CCMHP Peer Reference Form (For MDs, DOs and NPs ONLY)
• MHA22h - 274 Report Provider Information Form (Required for all providers – To be completed by Manager/Supervisor)
• Credentialing Packet (Forms combined - MHA12, MHA22 & MHA22c ONLY)

Recredentialing Forms

• MHA22b - Recredentialing Application (Required for all providers)
• MHA22h - 274 Report Provider Information Form (Required for all providers – To be completed by Manager/Supervisor)

Legal Name Change/Facility Change/Termination

• MHA22a - Facility Change Form
• MHA22d - Staff Termination Form
• MHA22e - Facility/Program Assignment Form
• MHA22f - Legal Name Change Form

Credentialing and Recredentialing Resources

• Help Sheet
• List of Accepted Taxonomy Codes
• NPI Registration & Taxonomy Alterations
• NPI Registration Changes
• Sample Provider Signature Sheet

Scope of Practice

• Guidelines for Scope of Practice:
  • Unlicensed Staff
  • Clinical Staff
  • Medical Staff
• Scope of Practice Definitions

Certification/Re-certification

• SD/MC Provider Certification & Re-certification Protocol
• SD/MC Provider Certification & Re-certification Site Visit Preparation Guide
• CCMHP Individual/Group Site Review

PAVE and Medi-Cal Rx Enrollment

• PAVE Step-by-Step Guide
• NPI Registration and Alterations
• Medi-Cal Rx Step-by-Step Guide
• How to Update Primary Practice Address on NPPES
• Frequently Asked Questions

Network Adequacy Certification Tool (NACT)

• Monthly 274 Provider Network Data Reporting Guide – To request a copy, please contact Provider Services.
• NACT Schedule
• NACT PowerPoint Training
• NACT PowerPoint Training (Printer Friendly)

ShareCare and Report Folder Access Request

• ShareCare and Report Folder Access Request Form

Beneficiary Protection Training

• Beneficiary Protection Training - PowerPoint
  - Beneficiary Protection Training (Printer Friendly)