Form Dhcs 1008 - California Quarterly Report On Services Provided To Persons Detained In Jail Facilities - Health And Human Services Agency

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State of California – Health and Human Services Agency
Department of Health Care Services
QUARTERLY REPORT ON SERVICES PROVIDED TO PERSONS
DETAINED IN JAIL FACILITIES
Year
County Name:
Quarter 1
July 1 to Sept. 30
County Code
:
Quarter 2
Oct. 1 to Dec. 31
Quarter 3
Jan. 1 to March 31
Quarter 4
April 1 to June 30
INVOLUNTARY
VOLUNTARY
Number of admissions to local inpatient services pursuant to PC
1.
4011.6 or PC 4011.8 evaluated and/or treated in a local mental health
facility.
Number of admissions to an LPS approved inpatient treatment
2.
program within a jail facility.
ALL FACILITIES MUST BE LPS APPROVED AND MEET INPATIENT SERVICE REQUIREMENTS AS
DEFINED IN CALIFORNIA ADMINISTRATIVE CODE, TITLE 9, ARTICLE 3, SECTION 820 & 821, AND
ARTICLE 10, SECTION 660-663.
Unduplicated count of persons receiving outpatient services as defined in the Cost Reporting
3.
Manual
(see Reporting Instructions on the next page or reverse side) provided within a jail facility.
The above information is required by the California Welfare and Institutions Code (WIC) Section
5402(a).
The information provided in this quarterly report will be incorporated into an annual report as required by
WIC Section 5402(d).
Please see the next page for Reporting Instructions.
th
This quarterly report should be submitted by the 30
of the month following the end of each
quarter via email, fax, or US Mail
If you need assistance preparing this report, please send an email to one of the persons below.
Fax Number:
(916) 552-8555
or
Email Address:
bryan.fisher@dhcs.ca.gov
kenneth.lee@dhcs.ca.gov
Mailing address:
DEPARTMENT OF HEALTH CARE SERVICES
Research and Analytic Studies Branch, MS1200
P.O. Box 997413
SACRAMENTO, CA 95899-7413
DATE
CONTACT PERSON
PHONE NUMBER
DHCS 1008 (08/12)

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