Form Dhcs 1011 - Califronia Convulsive Treatments Administered Quarterly Report - Health And Human Services Agency

Download a blank fillable Form Dhcs 1011 - Califronia Convulsive Treatments Administered Quarterly Report - Health And Human Services Agency in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Dhcs 1011 - Califronia Convulsive Treatments Administered Quarterly Report - Health And Human Services Agency with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

State of California Health and Human Services
Department of Health Care Services
DHCS 1011 (8/12)
State of California - Health and Human Services Agency
Department of Health Care Services
CONVULSIVE TREATMENTS ADMINISTERED – QUARTERLY REPORT
County
Reporting Facility or Doctor
Report Date
For Quarter Ending
Number of Patients Treated By
Private:
3rd Party Payor:
Major Source of Payment
______________
______________
Public:
Other:
______________
______________
SECTION I
NUMBER OF PATIENTS RECEIVING TREATMENT
AGE
SEX
RACE
PATIENT
DISTRIBUTION
PATIENT TYPE
Voluntary Patient -
0
0
0
With Informed Consent
Voluntary Patient - Not capable of
0
0
0
Informed Consent
Involuntary Patient -
0
0
0
With Informed Consent
Involuntary Patient - Not Capable of
0
0
0
Informed Consent
0 0 0 0 0 0 0
TOTALS
0 0 0 0 0 0 0
0 0
SECTION II
TOTAL TREATMENTS GIVEN
Convulsive Treatments
0
0
0
SECTION III
COMPLICATIONS ATTRIBUTABLE TO TREATMENT
Cardiac Arrest - Nonfatal
0
0
0
Memory Loss - reported
0
0
0
Fractures
0
0
0
Apnea
0
0
0
Death - No Coroner Report
0
0
0
Death - With Coronor Report
0
0
0
TOTALS
0 0 0 0 0 0 0
0 0
0 0 0 0 0 0 0
SECTION IV
EXCESSIVE TREATMENTS
Patients - Excessive Treatments
0
0
0
PREPARED BY:
SUBMIT TO:
County Mental Health Director
TELEPHONE NUMBER (including area code):
DO NOT MODIFY THIS FORM FOR SUBMITTAL TO THE DEPARTMENT OF HEALTH CARE SERVICES
DHCS 1011 (8/12)

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form Dhcs 1800 - California Electroconvulsive Treatment (ect), Informed Consent - Health And Human Services Agency Form Dhcs 1800 - California Electroconvulsive Treatment (ect), Informed Consent - Health And Human Services Agency Legal
Form Dhcs 5050 - California A-5 Facility Staffing Data - Health And Human Services Agency Form Dhcs 5050 - California A-5 Facility Staffing Data - Health And Human Services Agency Legal
Form Dhcs 0004 - Request For California Birth Record (vietnamese) - Health And Human Services Agency Form Dhcs 0004 - Request For California Birth Record (vietnamese) - Health And Human Services Agency Legal
Form Dhcs 0004 - California Request For California Birth Record - Health And Human Services Agency Form Dhcs 0004 - California Request For California Birth Record - Health And Human Services Agency Legal
Form Dhcs 4014 - California Children's Services Medical Report - Health And Human Services Agency Form Dhcs 4014 - California Children's Services Medical Report - Health And Human Services Agency Legal
Form Dhcs 1010 - California Quarterly Report On Involuntary Detentions - Health And Human Services Agency Form Dhcs 1010 - California Quarterly Report On Involuntary Detentions - Health And Human Services Agency Legal
Form Dhcs 7071 - California Medical Waiver Information And Authorization - Health And Human Services Agency Form Dhcs 7071 - California Medical Waiver Information And Authorization - Health And Human Services Agency Legal
Form Dhcs 0002 - Proof Of Citizenship And Identity (hmong) - Health And Human Services Agency Form Dhcs 0002 - Proof Of Citizenship And Identity (hmong) - Health And Human Services Agency Legal
Form Dhcs 1008 - California Quarterly Report On Services Provided To Persons Detained In Jail Facilities - Health And Human Services Agency Form Dhcs 1008 - California Quarterly Report On Services Provided To Persons Detained In Jail Facilities - Health And Human Services Agency Legal
Form Dhcs 1009 - California Quarterly Report Of Conservatorships Established By The Superior Court Of The County - Health And Human Services Agency Form Dhcs 1009 - California Quarterly Report Of Conservatorships Established By The Superior Court Of The County - Health And Human Services Agency Legal

Related Categories

Parent category: Legal
Download
Go
Page of 2