MH 515
Revised 02/06/08
Date: ____________ Telephone Contact: Y N Rendering Provider Face-to-Face/Other Time* (Hrs:Mins): _____________
Procedure Code: _______________ Other Staff Initials: ________ Total Time* (Hrs/Mins): _____________
* All travel and documentation time must be recorded as “Other” or “Total Time Other Staff Initials: ________ Total Time* (Hrs/Mins): _____________
MHS Activity Type: Assessment Ind Tx Ind Reh Col PsyT Team Conf/CaseCon
GrpTx GrpReh # of Clients Represented: ___________
Other Activity Type
: Cris lnt
Continued (Sign & complete claim information on last page of note.)
_______________________________________________ _____________ ______________________________________________ ____________
Signature & Discipline Date Co-signature & Discipline Date
This confidential information is provided to you in accord with
State and Federal laws and regulations including but not limited to
applicable Welfare and Institutions Code, Civil Code and HIPAA
Privacy Standards. Duplication of this information for further
disclosure is prohibited without the prior written authorization of
the patient/authorized representative to who it pertains unless
otherwise permitted by law.
Name: IS#:
Agency: Provider #:
Los Angeles County – Department of Mental Health