Forms for Providers
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.
Intensity of service dispute form
Complete the intensity of service dispute form if you wish to dispute PerformCare's intensity of service (IOS) determination.
Release of information form
The family should fax the completed form to PerformCare at 1-877-736-9166 to request a release of a youth's medical record.
- Release of information form (PDF).
Service desk request form
Complete the service desk online form to address CYBER technical issues, eligibility questions, provider information, etc. Please have your Medicaid number available.
Intellectual/Developmental Disability Services
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).
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 specialized residential treatment unit (SRTU), or are requesting a Tier II Consultation.
- OOH referral request checklist for document upload (PDF).
- SRTU cover letter for document upload (PDF).
- DCPP telephonic review fax cover sheet for document upload (PDF).
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
Initial Assessment for Substance Use Treatment
As part of the new substance use authorization process, substance use treatment providers are required to use the new Substance Use Treatment Initial Assessment form. All documents should be faxed to the PerformCare substance use provider fax number at 1-877-949-6590.
The 42 CFR Part 2 consent forms must be faxed on the first day of admission, and the initial clinical assessments should be faxed within the first 30 days of admission. The clinical documents must provide clinical justification for the youth's treatment at the requested intensity of service.
Do not use any other fax number associated with PerformCare for substance use treatment documents.
Substance use treatment consent and release form
This consent form is used exclusively by substance use providers and intensive in-community (IIC) assessors who specialize in substance use. Use it to disclose information to PerfomCare for referral and/or treatment. This is limited to:
- Substance use treatment providers contracted by DCF/CSOC.
- IIC assessors who have LCADC credentials submitting the Needs/BPS substance use assessment.
- Probation, parole, and juvenile court representatives sending PerformCare substance use information or assessments (this does not include juvenile detention center representatives).
All other providers and community partners should continue using the standard consent/release form.
Substance use treatment service-related documents that require faxing to PerformCare must be submitted via this dedicated, toll-free fax line: 1-877-949-6590. Do not use any other fax number associated with PerformCare for substance use treatment documents.