Get Worksheet: Mental Health Service Corps Behavioral Health Application

The Worksheet: Mental Health Service Corps Behavioral Health Application is a crucial document for organizations seeking to participate in mental health service programs. This guide provides step-by-step instructions to assist you in completing the form accurately and efficiently.

Follow the steps to complete your application online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with the leadership section by entering the name and title of the person responsible for Mental Health Service Corps activities at your site. Include their email address and direct phone number. Specify whether this individual will directly supervise the Corps Member at the site by selecting Yes or No.
3. In the hours of operation section, fill in the hours for each day of the week that your site operates.
4. Proceed to the electronic health record section. Provide details such as the hospital affiliations and name of the vendor for your electronic health record system. Indicate if the Patient Portal is activated by choosing Yes or No.
5. Skip to the space section and confirm the availability of resources, including a computer terminal with access to the practice’s EHR, consultation areas for privacy, and secured storage for materials. Answer each question with Yes or No.
6. In the written policies section, affirm whether there are written policies for appointment management, patient communications, external referrals, labs/imaging, and care coordination by selecting Yes or No for each policy listed.
7. In the patient panel section, record the number of unique patients and estimate the number of visits per year. Fill in the estimated percentages for pediatric and adult patients in the provided fields.
8. Complete the patient population composition section by estimating the demographic percentages of patients at your site and noting the top three languages spoken.
9. Indicate the top five frequent diagnoses at your site in the relevant fields.
10. For payer mix, estimate the percentages for Medicaid, Medicare, Dual Eligible, Private, and Uninsured/Self-Pay patients.
11. Finally, fill out the program enrollment justification section by responding to the prompts regarding unmet mental health needs, reasons for participating in the program, and expected outcomes for the practice and patients within 500 characters.
12. Once you have completed the form, ensure all information is accurate. Save your changes, and you may then download, print, or share the form as needed.

Complete your Worksheet: Mental Health Service Corps Behavioral Health Application online today to further mental health services at your site.