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PCC Plan Support Material Order Form


To order support materials, please fill out the form below. You can also fax this form with a cover page to 617-350-1982, Attn: PCC Plan.

PCC practice name: *Required
PCC contact person: *Required
PCC Plan Provider ID: *Required
Address: *Required
Address2:
City: *Required
State:  
Zip: *Required
Phone number: Example:6173501982 *Required
Date of request: (mm/dd/yyyy)  


Children's Behavioral Health Initiative
Item Number
Item Description
Quantity
 
CBHI - Central CBHI Family Brochure: Worried about the Way Your Child is Acting or Feeling ? Central
CBHI - Central (Por) CBHI Family Brochure: Worried about the Way Your Child is Acting or Feeling ? Central (Portuguese)
CBHI - Central (Sp) CBHI Family Brochure: Worried about the Way Your Child is Acting or Feeling ? Central (Spanish)
CBHI - Metro Boston CBHI Family Brochure: Worried about the Way Your Child is Acting or Feeling ? MetroBoston
CBHI - Metro Boston (Por) CBHI Family Brochure: Worried about the Way Your Child is Acting or Feeling? MetroBoston (Por)
CBHI - Metro Boston (Sp) CBHI Family Brochure: Worried about the Way Your Child is Acting or Feeling ? MetroBoston (Spanish)
CBHI - Northeastern CBHI Family Brochure: Worried about the Way Your Child is Acting or Feeling ? Northeastern
CBHI - Northeastern (Por) CBHI Family Brochure: Worried about the Way Your Child is Acting or Feeling ? Northeastern (Por)
CBHI - Northeastern (Sp) CBHI Family Brochure: Worried about the Way Your Child is Acting or Feeling ? Northeastern (Spanish)
CBHI - Southeastern CBHI Family Brochure: Worried about the Way Your Child is Acting or Feeling ? Southeastern
CBHI - Southeastern (Por) CBHI Family Brochure: Worried about the Way Your Child is Acting or Feeling ? Southeastern (Por)
CBHI - Southeastern (Sp) CBHI Family Brochure: Worried about the Way Your Child is Acting or Feeling ? Southeastern (Spanish)
CBHI - Western CBHI Family Brochure: Worried about the Way Your Child is Acting or Feeling ? Western
CBHI - Western (Por) CBHI Family Brochure: Worried about the Way Your Child is Acting or Feeling ? Western (Por)
CBHI - Western (Sp) CBHI Family Brochure: Worried about the Way Your Child is Acting or Feeling ? Western (Spanish)
CBHI-Table Children's Behavioral Health Initiative Table of Screen Tools (25max)
CMH How's Your Child's Mental Health? (Eng)
CMH (SP) How's Your Child's Mental Health? (Sp)
CRAFFT Toolkit Using the CRAFFT Screening Tool
M-CHAT M-CHAT (Eng)
M-CHAT (SP) M-CHAT (Sp)
PC-BH Toolkit Primary Care Behavioral Health Screening Toolkit (25max)
PHQ-9 PHQ-9 Depression Screening Tool (Eng/Sp)
PHQ-9 Scoring Tool PHQ-9 Scoring Tool
PSC Pediatric Symptom Checklist (PSC)
PSC-Y Pediatric Symptom Checklist Youth (Y-PSC)
PSC/PSC-Y Scoring Tool PSC/PSC-Y Scoring Instructions
SIW Screening Implementation Worksheet (25max)

Breast & Cervical Cancer Screening
Item Number
Item Description
Quantity
 
MAM-1 Mammograms - Not Just Once, But For a Lifetime
MAM-1 (SP) Mammograms - Not Just Once, But For a Lifetime (Sp)
PAP-1 The Pap Smear
PAP-1 (SP) The Pap Smear (Sp)

Perinatal Care
Item Number
Item Description
Quantity
 
DEN-03 Oral Health Tidbits (Eng/Sp)
HB-1 Recipe for a Healthy Baby (Eng)
HB-1 (SP) Recipe for a Healthy Baby (Sp)
HPG Healthy Pregnancy Guide (Eng)
OBRA Obstetrical Risk Assessment Form
PPV-1 Postpartum Visit Reminder Card
PPV-2 Mothers Are Special, Too... (Eng)
PPV-2 (SP) Mothers Are Special, Too... (Sp)

Well-Child Care
Item Number
Item Description
Quantity
 
ChPr Choosing a Doctor or Nurse Practitioner for Your Child (Eng)
ChPr (SP) Choosing a Doctor or Nurse Practitioner for Your Child (Sp)
ECD Quick Guide to Early Childhood Dental Care
EPSDT-BG EPSDT & PPHSD Services Billing Guidelines for MassHealth Physicians and Mid-level Providers (25max)
EPSDT-CD Child Adolescent Well-Visit Schedule (Eng/Sp)
GC Growth Chart (Eng)
GC (SP) Growth Chart (Sp)
MDHP/MIP Pediatric Vaccine Administration Record
MHQP-Ped/Adult MHQP Pediatric and Adult Desktop Guidelines (25max)
Reminder Reminder Card

Wellness Promotion
Item Number
Item Description
Quantity
 
MDHP/AMIP Adult Vaccine Administration Record
Obesity - MIP Addressing Obesity in the Primary Care Setting
Well Teen Well Visit Poster (Adolescent) (Eng)
Well Teen (SP) Well Visit Poster (Adolescent) (Sp)
Well Tips Ask Me 3 Tip Sheet
Well Visit Poster Well Visit Poster (Adult) (Eng/Sp)
Well-1 MassHealth Wellness Brochure (Eng/Sp)

Adult Behavioral Health
Item Number
Item Description
Quantity
 
Dep Treating Depression (Eng) (50max)
Dep (SP) Treating Depression (Sp) (50max)
HP Caring for the Homeless and Marginally Housed (25max)
SMI Providing Care to Members with Serious Mental Illness (25max)
WID What is Depression? (Eng/Sp)

Asthma Management
Item Number
Item Description
Quantity
 
AFS-1 Asthma
AFS-2 How Can I Control My Asthma?

Diabetes Management
Item Number
Item Description
Quantity
 
DB729 Diabetes Fact Sheets - set
DFS-6 Diabetes and Depression Fact Sheet (Eng/Sp)
DRC Diabetes Reminder Card

Emergency Department (ED) Utilization
Item Number
Item Description
Quantity
 
ED-2 Before You Go to the Emergency Room
PCC-ED-Adult ED Follow-up Card: Adult
PCC-ED-Child ED Follow-up Card: Child
PCC Plan Resource Materials
Item Number
Item Description
Quantity
 
MBHP Mental Health How can MBHP Help Me? (Eng)


*All items from the Massachusetts Health Promotion Clearing House Catalog can be ordered on-line at www.maclearinghouse.com or by phone at 1-800-952-6637.


                            



MBHP - Massachusetts Behavioral Health Partnership
1000 Washington Street, Suite 310, 3rd Floor, Boston, MA 02118-5002   1-800-495-0086
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This page was last updated: 12/3/2012