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Forms

Clinical summary template

Providers 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. It is used for any of the following reasons:

  1. Connecting with New Jersey Children’s System of Care (CSOC) Care Management services.
  2. A supplemental document for care management-linked youth, who currently receive community-based therapeutic services, and are referred for out-of-home treatment.
  3. Potential linkage to other CSOC services.

If you need more information regarding the clinical summary template (DOC), or referring a child for CSOC services, call PerformCare at 1-877-652-7624.

Intensity of Service (IOS) dispute form

For instances when providers wish to dispute PerformCare's Intensity of Service (IOS) determination.

Out-of-home (OOH) referral packet checklist

For instances when a provider is referred to the Division of Children's System of Care (CSOC) specialized residential treatment unit (SRTU) or is requesting a Tier II Consultation.

Consent to release protected health information (PHI) form

To be completed by the family and faxed to PerformCare at 1-877-736-9166 to request a release of a youth's medical record.

Service desk request form

An online form that can be completed to address CYBER technical issues, eligibility questions, provider information, etc. Please have your Medicaid number available.

Tier II Consultation form

In instances where providers are requesting a Tier II Consultation determination.