Forms for Providers
All providers
Customer Service Request Form
Complete this online Customer Service Request Form to address CYBER technical issues, and questions regarding clinical, billing, eligibility, and reporting issues. You will need your Provider Agency ID available to submit a request.
Clinical summary template
Complete the clinical summary template (DOC) to assist in the determination of an appropriate intensity of service in the management of a youth's emotional and behavioral needs for any of the following reasons:
- Connecting with New Jersey Children's System of Care (CSOC) Care Management services.
- A supplemental document for care management-linked youth, who currently receive community-based therapeutic services, and are referred for out-of-home treatment.
- Potential linkage to other CSOC services.
If you need more information regarding the clinical summary template, or referring a child for CSOC services, call PerformCare at 1-877-652-7624.
Authorization for Sharing Health Information Forms
| Language | Links |
|---|---|
| English | Authorization for Sharing Health Information Form (PDF) Frequently Asked Questions — Authorization for Sharing Health Information (PDF) |
| Español (Spanish) | Autorización para compartir información médica (PDF) Formulario de Autorización de divulgación de información médica: Preguntas frecuentes (PDF) |
| Português (Portuguese) | Autorização para compartilhar informações médicas (PDF) |
| 中文（普通话） (Chinese (Mandarin)) | 健康信息分享授权 (PDF) |
| 中文（粵語） (Chinese (Cantonese)) | 健康資訊分享授權 (PDF) |
| 한국어 (Korean) | |
| ગુજરાતી (Gujarati) | |
| عربي (Arabic) | تصريح لمشاركة المعلومات الصحية (PDF) |
| kreyòl ayisyen (Haitian Creole) | Otorizasyon pou pataje enfòmasyon sante (PDF) |
Additional Substance Use Treatment Information
- Children’s System of Care (CSOC) Provider Directory: Substance Use Treatment Service Providers (PDF)
Intensity of service dispute form
Complete the intensity of service dispute form if you wish to dispute PerformCare's intensity of service (IOS) determination.
Intellectual/Developmental Disability Services
Crisis Stabilization and Assessment Program (CSAP-IDD) referral form
This form can be used by CMO or MRSS providers to refer youth to the Crisis Stabilization and Assessment Program (CSAP-IDD). CSAP provides 24-hour care in a highly structured, community-based treatment setting with professional competencies and capabilities to stabilize youth with intellectual/developmental disabilities (I/DD) in crisis who are unable to be safely supported in their current living situation.
The Child Adaptive Behavior Summary (CABS) is also required as part of the Crisis Stabilization and Assessment for I/DD (CSAP-IDD) referral. The CABS should be completed and signed by the youth’s primary caregiver — the person who is most familiar with the youth. The CABS can be used as a fillable PDF, or printed out and completed by hand.
Individual Support Services - CABS
Activities of daily living (ADLs) consist of self-care tasks and Instrumental ADLs enable an individual to live independently in the community. An Individual Support Technician must arrange to meet with the parent/legal guardian/custodian and jointly complete the Child Adaptive Behavior Summary (CABS).
Intermediate Inpatient Units
Interventionist Supporting Document
Intermediate Inpatient Unit (IU) providers should use the interventionist support document (ISD) to request a continued stay authorization or a transition.
Out-of-Home (OOH) providers
Out-of-home (OOH) referral packet checklist
Complete this packet if you are referred to the Division of Children's System of Care, CSOC Office of Residential Services (ORS – formerly SRTU), or are requesting a Tier II Consultation.
- OOH referral request checklist for document upload (PDF).
- Access to ORS information (PDF).
- ORS/SRTU cover letter for document upload (PDF).
- DCPP telephonic review fax cover sheet for document upload (PDF).
Child Adaptive Behavior Summary (CABS)
The Child Adaptive Behavior Summary (CABS) should be used for Out-of-Home referrals involving youth who are either eligible for intellectual/developmental disability (I/DD) services through CSOC or if the I/DD module has been completed in the Strengths and Needs Assessment.
The CABS is also required as part of the Crisis Stabilization and Assessment for I/DD (CSAP-IDD) referral.
The CABS should be completed and signed by the youth's primary caregiver —the person who is most familiar with the youth. The CABS can be used as a fillable PDF, or printed out and completed by hand.
Tier II Consultation form
Complete the Tier II Consultation form to request a Tier II Consultation determination.
- Tier II Consultation process (PDF).
- Tier II Consultation tips for CMEs (PDF).
- Tier II Consultation request form (PDF).
Transitional Joint Care Review (TJCR)
Create a TJCR when the Child Family Team agrees that a transition from one OOH provider to another will best meet the needs of the child.
Substance Use Treatment Services
Substance Use Treatment Initial Assessment
The Substance Use Treatment Initial Assessment (PDF) should only be completed by CSOC-contracted outpatient substance use treatment (SUT) providers. This form is required to obtain service authorization through PerformCare. Fax all required documents to the designated PerformCare SUT provider fax number: 1-877-949-6590.
The 42 CFR Part 2 compliant consent form must be faxed to PerformCare on the first day of admission while the initial clinical assessments must be faxed within the first five days of admission. Submitted documents must provide clinical justification for the youth's treatment at the requested intensity of service.
Do not send SUT documents to any other fax number associated with PerformCare.
Informed Consent Form for Sharing Protected Health and Substance Use Information
Please use the Informed Consent Form for Sharing Protected Health and Substance Use Information (42 CFR Part 2 compliant form) to disclose referral and/or treatment information to PerformCare. This form may only be used by:
- DCF/CSOC-contracted SUT providers.
- Intensive In-Community (IIC) assessors who hold Licensed Clinical Alcohol and Drug Counselor (LCADC) credentials and are submitting the Needs/Biopsychosocial (BPS) substance use assessment to PerformCare.
- Probation, parole, and juvenile court representatives submitting substance use information or assessments to PerformCare (excluding representatives from juvenile detention centers).
All other providers and community partners should use the Authorization for Sharing Health Information Form (PDF) for the consent/release of sensitive information.
SUT service documents must be submitted to PerformCare via the designated, toll-free fax: 1-877-949-6590. Do not send SUT documents to any other fax number associated with PerformCare.
Informed Consent for Sharing Protected Health and Substance Use Information Forms
| Language | Links |
|---|---|
| English | Authorization Form for Sharing Protected Health and Substance Use Information (PDF) Explanation of Informed Consent Form for Sharing Protected Health and Substance Use Information (PDF) |
| Español (Spanish) | Formulario de consentimiento informado para compartir información médica protegida y de uso de sustancias (PDF) |
| Português (Portuguese) | Formulário de Consentimento Informado para Compartilhamento de Informações Protegidas sobre Saúde e Uso de Substâncias (PDF) |
| 中文（普通话） (Chinese (Mandarin)) | 知情同意书: 共享受保护健康及物质使用信息 (PDF) |
| 中文（粵語） (Chinese (Cantonese)) | 分享受保護健康及藥物使用資訊之知情同意書 (PDF) |
| 한국어 (Korean) | |
| ગુજરાતી (Gujarati) | સુરક્ષિત સ્વાસ્થ્ય અને માદક પદાર્થના સેવનની માહિતી શેર કરવા માટે જાણકાર સંમતિ ફોર્મ (PDF) |
| عربي (Arabic) | نموذج موافقة مستنيرة لمشاركة المعلومات الصحية المحمية ومعلومات تعاطي المواد (PDF) |
| kreyòl ayisyen (Haitian Creole) | Fòm konsantman eklere pou pataj enfòmasyon ki pwoteje sou sante ak abi sibstans (PDF) |
Additional Substance Use Treatment Information
- Children’s System of Care (CSOC) Provider Directory: Substance Use Treatment Service Providers (PDF)