Dhhs p&p template

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Provider Sample

Staff Waiver Application

Policy and Procedure

Policy Issuer (Unit/Program)


Policy Number

Effective Date

Revision Date


Staff Registration

Functional Area:

Beneficiary Protection

Approved By: (Signature on File)

Program Director, Quality Management


Contracted Alameda County Providers are responsible for assuring that the mental health services provided are commensurate with the scope of practice, training and experience of the staff utilized. XYZ Service Agency - Quality Management (QM) must certify all staff that provides mental health and alcohol and drug services in accordance with Title 9, Welfare and Institution Code, and Business and Profession Code regulations. In addition, QM, in accordination with Human Resources maintains confirmation of licensure for the XYZ County staff performing in a licensed position whether or not they provide direct mental health services even if they do not bill for those services provided.

Licensed Professional of the Healing Arts (LPHA)

An LPHA is an individual who can function as “Head of Service” on the agency application and possesses a valid California License in one of the following professional categories:

  1. Psychiatrist, Medical Doctor, Psychiatric Resident (Licensed or Unlicensed) (MD)

  2. Licensed Clinical Psychologist (PSY)

  3. Licensed Clinical Social Worker (LCSW)

  4. Licensed Marriage and Family Therapist (LMFT)

  5. Licensed Professional Clinical Counselor I (LPCC I)

  6. Licensed Professional Clinical Counselor II*(LPCC II)*

  7. Registered Nurse, Nurse Practitioner, Nurse Practitioner Intern (RN, NP, NPI)

  8. Physician Assistant (PA)

*The Licensed Professional Clinical Counselor II classified as an LPHA must verify completion of additional training and education of six semester units or nine quarter units specifically focused on the theory and application of marriage and family therapy or a named specialization or emphasis are on the qualifying degree in marriage and family therapy, marital and family therapy, marriage, family and child counseling; or couple and family therapy. In addition, submit proof on no less than 500 hours of documented supervised experience working directly with couples, families, or children and a minimum of six hours of continuing education specific to marriage and family therapy, completed in each licensed renewal cycle. Business and Professions Code 4999.

Licensed Waived

A “waived” individual may function as an LPHA with the exception of “Head of Service”. This individual is a Marriage and Family Intern (IMF), an Associate Social Worker (ASW), Professional Clinical Counselor Intern (PCCI), Registered Psychologist (RPS) or a Registered Psychological Assistant (PSB) and is registered with their respective Board and is one of the following:

  1. An individual with a Master’s Degree who is granted a waiver by the County, which allows them to function as an LPHA for up to six years.

  2. An individual with a PhD who has registered with the Board of Psychology and is granted a waiver by the State Department of Health Care Services*, (See Business and Professions Code Section 2909)

*See P & P #03-06 Licensure Waiver and Monitoring of Accrued Supervised Hours for details.

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