DHS 35 - WI Department of Health Services Resources
Resources for Outpatient Mental Health Clinics


Considerations regarding use of the documents on this DHS 35 webpage

  • DHS 35, the New Outpatient Mental Health Clinic Rule (DQA-DMHSAS Memo 09-008, March 2009)

  • DHS Frequently Asked Questions about DHS 35

  • DHS 35: Outpatient Mental Health Clinic Rules - The Complete Text of the Administrative Rule

  • Division of Quality Assurance

  • Consumer Guide to Health Care - Finding and Choosing Mental Health Care Treatment Programs

  • DHS Official Application Forms

  • DHS Website

    Under Mental Health Treatment Programs you will find many useful resources at your fingertips.

    Forms Library and Webcast Library are the two most important resources. Several important forms are listed below for your convenience, but take a look at the entire list to find other forms that can assist your organization.

    Forms Library – forms can be located by using the lists located in the left column:

    alphabetic forms lists – form by name
    numeric lists – form by number
    division/office numeric lists – form by division/office

    Division/Office Links of greatest interest for clinics and residential treatment facilities:

    DCTS - Division of Care and Treatment Services
    DQA – Quality Assurance
    DMS – Division of Medicaid Services (BadgerCare)

    NOTE: many forms are available as a PDF or a Word Doc that can be edited for your organization’s use; some forms are available in Spanish and Hmong

    DCTS 

    F-22538 – PDF – Consent to Film or Tape

    F-22538 – Word – Consent to Film or Tape

    F-22538S – PDF – Consent to Film or Tape - Spanish

    F-24277 BRD – PDF - Informed Consents for Medications: Brand Name Index

    F-24277 GEN – PDF - Informed Consents for Medications: Generic Name Index

    F-26003 – PDF – Notice of Privacy Practices - Treatment Facilities

    F-26030 – Word – Notice of Privacy Practices - Treatment Facilities

    F-26003H- PDF – Notice of Privacy Practices - Treatment Facilities - Hmong

    F-26003S – PDF – Notice of Privacy Practices - Treatment Facilities - Spanish

    F-26100 – PDF – Clients Rights Limitation or Denial Documentation

    DQA

    F-62504  – Community Based Substance Abuse Services Or Mental Health Clinic Certification Application

    F-62520 – PDF – Caregiver Program Compliance Check

    F-62520 – Word – Caregiver Program Compliance Check

    F-62569 – PDF – Application for Individual Provider Status Approval (unlicensed provider)

    F-62569 – Word – Application for Individual Provider Status Approval (unlicensed provider)

    F-62570 – PDF – Supervisor Affidavit

    F-62570 – Word – Supervisor Affidavit

    F-62589 – PDF – Request for Approval to Use TeleHealth (policy & procedure / Medicaid billing)

    F-62589 – Word – Request for Approval to Use TeleHealth (policy & procedure / Medicaid billing)

    DMS

    F-00212 – Word - ForwardHealth Prior Authorization Intensive In-Home MHSA Services Assessment and Recovery / Treatment Plan (health check has to be done as a prior auth issue for in-home treatment of children)

    F-00212a – PDF - Completion Instructions

    HCF

    F-11018 – PDF - ForwardHealth Prior Authorization

    F-11018 – Word - ForwardHealth Prior Authorization

    F-11031 - PDF - Wisconsin Medicaid Prior Authorization / Psychotherapy Attachment (PA/PSYA)

    F-11031 - Word - Wisconsin Medicaid Prior Authorization / Psychotherapy Attachment (PA/PSYA)

    F-11031a – PDF - Completion Instructions

    F-11036 – Word - ForwardHealth Prior Authorization / In-Home Treatment Attachment (PA / ITA)

    F-11103 – PDF - Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan

    F-11103 – Word - Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan

    F-11103a – PDF - Completion Instructions (includes data elements required by Medicaid)

    HFS

    F-82009 – PDF – Confidential Information Release Authorization

    F-82009 – Word – Confidential Information Release Authorization

    Several Versions exist of this Form. Visit HFS forms page for more information.

    F-82064 – PDF – Background Information Disclosure and Instructions (caregiver background check)

    F-82064 – Word – Background Information Disclosure and Instructions (caregiver background check)

    Webcast Library – webcasts can be viewed online at your convenience and at no cost. The webcasts cover meetings, events and presentations by DHS staff and partners in the community.




(All documents are posted in Microsoft Word 2003 unless otherwise noted. If you receive a "login" prompt when you are trying to save one of these documents to your computer, hit "cancel" in the login box to proceed.)