MCUP3101 Attachment D
Application to be a
Contracted Brief Intervention/Referral to Treatment Provider
For Partnership HealthPlan of California
Name of Organization:______________________________
Address and Phone Number of Organization: _____________________
Organizational Contact for Questions: Name: __________________________email:____________
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Primary Care Organization(s) that will be referring patients for Brief Intervention/Referral to
Treatment:
Name of Organization(s) (or individual clinicians, if in solo/small group practice), City and County where
PCP locations located who are referring BIRT to applicant: ____________________________________
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List of clinicians who will be performing Brief Intervention and Referral to Therapy services
o Name
o Licensure Type
o SBIRT-related Training (description of training, length of training)
Submit Organizational Policy/Procedures describing how Brief Intervention and Referral to
Treatment (BIRT) will be performed, including Training requirements, Flow of patients, Quality
Assurance related to BIRT.
Submit 3 samples (with patient identifying details redacted) of clinical documentation for Brief
Intervention.
Attestation of supervision Physician or Psychologist:
I attest that I oversee Brief Intervention and Referral to Treatment services for alcohol misuse/abuse for
adults, performed at my institution for patients referred by local Primary Care Providers. I will assure
that the staff above are well trained and competent at performing these services. I certify that the
above application is accurate.
Name of supervising Clinician:________________________
Title of Supervising Clinician:_________________________
Date of signature:____________________________
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