Provider Services
For accessibility issues, please contact Provider Services at 925-608-6790.
Directory
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 has changed effective March 12, 2023
- 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:
- 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)