Medical Record Forms and Aids
Provider Type
- Physicians
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
Health Net's Medi-Cal Facility Site Review (FSR) Compliance Department has various medical record documentation forms and aids for participating providers. These forms and aids have been maintained to meet documentation standards as required by the Department of Health Care Services (DHCS) for Medi-Cal members.
- Advance Directive Labels (PDF)
- Audiometric Screening form (PDF)
- CPSP - Combined Postpartum Assessment (PDF)
- CPSP - Documentation of HIV Information (PDF)
- CPSP - Domestic Violence Danger Assessment (PDF)
- CPSP - Encounter (PDF)
- CPSP - Individual Care Plan (PDF)
- CPSP - Perinatal Food Frequency Questionnaire (PDF)
- CPSP - Prenatal Combined Assessment/Reassessment (PDF)
- History Form - English (PDF)
- History Form - Spanish (PDF)
- Initial Health Assessment (IHA) Tickler Log (PDF)
- Language Labels (PDF)
- Message Log (PDF)
- Preventive Care Forms (PDF)
- Referral Log (PDF)
- Signature Page (PDF)