FCM has the ability to hold a variety of documents in a member's chart. Please see below for the different categories and documents types within each category, for reference:
Additional Consent & Enrollment
| DOH 5203 - Release of Educational Records Consent |
| DOH 5204 - Withdrawal of Release of Educational Consents |
| DOH 5230 - Functional Assessment Consent |
| DOH 5032 - Authorization for Release of Health Information |
| Notice of Determination 5236 - Denial of Enrollment |
| Notice of Determination 5234 - Enrollment |
| Notice of Determination 5235 - Disenrollment |
| PSYCKES Consent |
| HIPAA Release Form |
| DOH 5058 - Withdrawal of Consent - Adults |
| DOH 5202 - Withdrawal of Consent - Children |
| RHIO Consent |
| Enrollment Letter |
| Case Closure Letter |
| Disenrollment Letter |
| Healthix Denial of Consent |
| Notice of Privacy Practices Acknowledgement |
| DOH-5059 Opt Out (Outreach Only) |
| DOH 5287 - Notice of Decision for Enrollment or Denial in 1915c Children's Waiver |
| DOH 5288 - Notice of Decision for Discontinuance in 1915c Children's Waiver |
| Health Home Referral |
| Transfer |
| Other |
| VNSNY Electronic Communication consent |
| VNSNY Patient Acknowledgement |
| OMH consent |
| DOH 5201 Tracking Form for Section 2 |
| Historical Documents |
| PSYCKES Supporting Documentation |
| DOH- 5275 LPHA Attestation |
| FAQ |
| Referral Face Sheet |
Housing
| Housing Application |
| HASA Application |
| Other |
Income & Entitlements
| Social Security |
| SNAP Benefits |
| Recertification Information |
| Other |
Legal
| Incarceration Documentation |
| Living Will |
| Power of Attorney |
| Advance Directive |
| Legal Guardian Documentation |
| AOT court order |
| AOT treatment plan |
| AOT monthly treatment verification |
| Fair Hearing |
| Other |
| AOT Portal Notes |
Medical
| Clinical Verification for Enrollment |
| Billing Support Questionnaire Documentation |
| Admission Documentation - Medical Hospitalization |
| Admission Documentation- Mental Health Hospitalization |
| Admission Documentation - Nursing Home |
| Admission Documentation - Substance Use Treatment |
| Admission Documentation - Other |
| Discharge Documentation - Medical Hospitalization |
| Discharge Documentation - Mental Health Hospitalization |
| Discharge Documentation - Nursing Home |
| Discharge Documentation - Substance Use Treatment |
| Discharge Documentation - Other |
| Lab Results |
| Provider Notes |
| PSYCKES Clinical Summary |
| Provider Referral |
| Complex Trauma Exposure Screen |
| Complex Trauma Eligibility Determination |
| Other |
| Children's Quarterly Eligibility Review |
| Children's Eligibility and Appropriateness Checklist |
| Medicaid Eligibility |
| Complex Trauma Exposure Assessment |
| HHSC Complex Trauma Referral Cover Sheet |
| Provider Visit Details |
| SED Verification Documentation |
| Medication |
| Medications |
| Mental Health Assessment |
| Medical/Physical/Dental |
Other
| Patient Bill of Rights |
| CANS Assessment |
| Individualized Education Plan (CPSE or CSE) |
| Health Home Discharge Plan |
| MLTC Plan of Care |
| Foster Care Family Assessment Service Plan |
| Safety and Disaster Plan |
| Other |
| Care Plan |
| Agency Written Notification Letter |
| CBC 10 Elements |
| CBC Initial Eligibility |
| CBC PHQ-9 |
| HARP |
| Interdisciplinary Meeting Documentation |
| Educational Records |
| HCBS |
| CAIRS follow Up Assessment |
| SPOA Referral Packet |
| CANS-Supporting Docs |
Adult Home Plus
Health Home Plus
| HH+ HIV Eligibility |
| HH+ SMI Eligibility |
| HH+ Supporting Documentation |
Early Intervention
| Early Intervention Note |
| Early Intervention IFSP |
| Early Intervention Progress Report |
| Other |
HCBS Waiver
| DOH 5276 Freedom of Choice Form (HCBS) |
| HCBS/LOC Eligibility Determination |
| DOH 5287 HCBS Notice of Decision |
| Children's HCBS Authorization and Care Manager Notification Form |
| DOH 5275 - Licensed Practitioner of the Healing Arts Attestation |
|
CYES Packet
|
| DOH 5144 Disability Review Team Certificate |
| Social Security Packet |
| Other |
Questions? Email us at
fcm-support@footholdtechnology.com