Form Sr 2c-Wp - Mental Health Component Program Audit Working Paper
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1STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Initials
Date
Prepared By
MENTAL HEALTH COMPONENT PROGRAM AUDIT
Approved By
WORKING PAPER (SR 2C-WP)
PROVIDER NAME:
PROGRAM NAME:
PROGRAM NUMBER:
PROGRAM AUDIT DATE:
EMPLOYEE/CONTRACTOR:
AUDIT PERIOD:
A. DOCUMENTATION REVIEWED:
Cancelled Checks
Client Files
Contracts
Itemized Billing
Medi-Cal
MH Verif Form
Payment by County Mental Health
Payroll Records
Timesheets
Other - Specify: _____________
Comments:
B. PROFESSIONAL LEVEL VERIFICATION (SR 2C - Column B) (Refer to MPP Section 11-402.223)
Reported:
Psychiatrist (5.0)
Psychologist (5.0)
LCSW (2.5)
MFT (2.5)
Interns/Other MH Prof. (1.0)
Verified:
Psychiatrist (5.0)
Psychologist (5.0)
LCSW (2.5)
MFT (2.5)
Interns/Other MH Prof. (1.0)
Documentation Reviewed:
Dept. of Consumer Affairs License
American Board of Psychiatry & Neurology
Certification by Hospital
MH Verif. Forms
Internet
Other
Comments:
If the audited weighting is different from provider's weighting:
No current license on file
Employee does not qualify under regulations as a mental health provider
SR 2C-WP (12/02)
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