CA DHCS 1808 (formerly MH 1760) 2019-2025 free printable template

State of California Health and Human Services AgencyDepartment of Health Care ServicesNOTICE OF CERTIFICATION FOR INTENSIVE TREATMENT PURSUANT TO SECTION 5250 (14 DAYS INTENSIVE TREATMENT) OR 5270.15

How to fill out california dhcs1808 fillable form

How to fill out CA DHCS 1808 (formerly MH 1760)

1. Step 1: Obtain the CA DHCS 1808 form from the official website or a local health office.
2. Step 2: Fill in the patient's personal information, including name, date of birth, and address.
3. Step 3: Provide information about the patient's insurance, including policy number and group number.
4. Step 4: Complete the section detailing the patient's medical history, including any relevant diagnoses and treatments.
5. Step 5: Sign and date the form to certify that the information provided is accurate.
6. Step 6: Submit the completed form to the appropriate department or agency as indicated in the instructions.

Who needs CA DHCS 1808 (formerly MH 1760)?

1. Individuals seeking mental health services under California's Department of Health Care Services.
2. Patients who require authorization for specific mental health treatments.
3. Caregivers or guardians filling out the form on behalf of a minor or incapacitated person.

People Also Ask about notice certification treatment

What is a 72 hour psychiatric hold in Arizona?

Within 72 hours of the court order, at least two physicians must meet with the person and conduct an evaluation and may recommend immediate treatment for the person, including medication, but the person maintains the right to refuse treatment during the time of the evaluation.

What happens after a 72 hour psych hold in California?

If you are held beyond 72 hours, you have the right to remain in the hospital for voluntary treatment. If you do not want to stay voluntarily, the facility where you are staying will conduct a certification review hearing within four days of the end of your 72-hour hold.

What is the criteria for 5250?

WIC § 5250. Most often, someone who is considered a danger to themselves has threatened or attempted self-harm or suicide. Threats or actual attempts to harm others are the most common way to meet this criterion.

What is the difference between 5150 and 5250?

While 5150 holds can only last up to 72 hours, 5250 holds can include up to 14 days of involuntary mental health treatment. However, before a 5250 hold is granted, you will have the right to attend a certification review hearing.

What happens after a 5250 hold?

5250 or 14 day hold Additional holds once the first 14 day hold expires if the patient continues to meet criteria for involuntary hospitalization, the treatment team may extend the hold. For Danger to Self: Another 14 day hold may be placed at which time a new PC Hearing takes place.

For pdfFiller’s FAQs

What is 5250 form?

The 5250 form refers to a legal document used in the State of California for involuntary psychiatric holds. It is also known as a "5150 hold" or a "72-hour hold." The form is used by mental health professionals, law enforcement, or designated personnel to temporarily detain and evaluate individuals who are deemed to be a danger to themselves or others due to a mental health condition. The form grants authorization for the person to be held involuntarily for up to 72 hours in a psychiatric facility for assessment and potential treatment.

Who is required to file 5250 form?

The 5250 form is used for requesting a 72-hour involuntary hold for individuals who are believed to be a danger to themselves or others due to a mental disorder. This form is typically filed by mental health professionals, such as psychiatrists or physicians, who have evaluated the individual and determined that they meet the criteria for involuntary psychiatric hospitalization.

How to fill out 5250 form?

To fill out the 5250 form, follow these steps: 1. Obtain the form: Get a copy of the 5250 form from the relevant authority or organization that requires it. You may also be able to find a printable version online. 2. Provide personal information: Fill in your personal details, such as your full name, address, contact number, and email address. Make sure to provide accurate information. 3. Specify the purpose: Indicate the purpose for which you are filling out the form. For example, if it is for a job application, state the position you are applying for. 4. Answer questions: Read and respond to the questions and prompts on the form. Some questions may require a yes or no answer, while others may ask for specific information or details. Provide concise and accurate responses. 5. Attach required documents: If there are any supporting documents required, make sure to attach them to the form. This could include identification documents, certificates, or any other relevant paperwork. 6. Review and sign: Read through the completed form carefully to ensure all information is correct and complete. If everything is accurate, sign and date the form. 7. Submit the form: Once you have filled out the form and reviewed it, you can submit it according to the instructions provided. This could involve mailing it, submitting it online, or delivering it in person. Remember to keep a copy of the filled-out form for your records.

What is the purpose of 5250 form?

The 5250 form refers to the California Welfare and Institutions Code Section 5250, which authorizes the involuntary detention and evaluation of individuals with mental health disorders who are a danger to themselves or others, or are gravely disabled. The purpose of the 5250 form is to initiate a 72-hour hold on the individual, during which they can be assessed and treated in a psychiatric facility. This form is typically used in emergency situations when there is an imminent risk to the person's safety or the safety of others due to their mental health condition.

What information must be reported on 5250 form?

The 5250 form is used by the U.S. Department of Labor's Office of Workers' Compensation Programs to report the payment of compensation and medical benefits to federal employees under the Federal Employees' Compensation Act (FECA). The following information must be reported on the 5250 form: 1. Federal agency information: The name, address, and identification number of the federal agency employing the injured worker. 2. Employee information: The name, Social Security number, and occupation of the injured federal employee. 3. Injury details: The date, time, and description of the accident or incident that caused the injury. 4. Wage information: The employee's regular wage rate and the period covered by the payment. 5. Compensation and benefits: The amount of compensation and medical benefits paid to the injured employee, including the date and type of payment (e.g., temporary total disability, permanent partial disability, medical treatment, vocational rehabilitation, death benefits, etc.). 6. Rehabilitation status: Information regarding the employee's rehabilitation status, such as whether they are undergoing vocational rehabilitation or have been declared permanently disabled. 7. Subsequent payments: Any additional payments made after the initial report, such as wage continuation or modifications to the compensation benefits. 8. Reporting party information: The name, title, and contact information of the person completing the form. It is important to note that the specific information required on the 5250 form may vary depending on the circumstances of the claim, and it is always advisable to consult the latest instructions and guidelines provided by the Office of Workers' Compensation Programs or seek professional assistance when completing the form.

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What is CA DHCS 1808 (formerly MH 1760)?

CA DHCS 1808, formerly known as MH 1760, is a standardized form used in California for the reporting of mental health data to the Department of Health Care Services.

Who is required to file CA DHCS 1808 (formerly MH 1760)?

Providers of mental health services who are participating in state-funded programs are required to file the CA DHCS 1808 form.

How to fill out CA DHCS 1808 (formerly MH 1760)?

To fill out CA DHCS 1808, providers must accurately complete all sections of the form, including patient identification, service details, and relevant clinical information.

What is the purpose of CA DHCS 1808 (formerly MH 1760)?

The purpose of CA DHCS 1808 is to collect and report data that supports mental health program accountability, funding, and services assessment within California.

What information must be reported on CA DHCS 1808 (formerly MH 1760)?

The CA DHCS 1808 form requires information such as patient demographics, service types provided, treatment dates, and clinical outcomes.