COBRA Resource Center

FORMS

• Sample COBRA Brief Intake/Assessment (6-06 version)
• Assessment
• Initial Comprehensive Assessment with Outcomes Sections Numbered
      *PDF version (recommended)
      *WORD version (use only if you need to reformat the assessment)
• Reassessment
• Comprehensive Reassessment with Outcomes Sections Numbered
      *PDF version (recommended)
      *WORD version (use only if you need to reformat the reassessment)
• Medications page-updated 7/8/10
       *Medications page (Landscape version)
      *Patient Resource Guide (3/31/09)
      *Med list 12/23/08 Intro Letter
      *Med list 6/30/09 Intro Letter
      *Med list 9/30/09 Intro Letter
      *Med list 3/31/10 Intro Letter
      *Med list 6/30/10 Intro Letter
      *Aptivus (6/08)
      *Kaletra (6/08)
      *Invirase - Health Care Professional Letter (6/08)
      *Health Care Professional Letter (3/08)
      *Intelence - Prescribing Information (3/08)
      *Intelence - Release Information (3/08)
      *Isentress Information Page
      *Atazanavir Sulfate Information Page (9/08)
      *NFV Prescribing Information (9/08)
      *Norvir [pages 40 through 47] (9/08)
      *Intelence - Important Drug Warning (9/09)
       *WebMD - FDA (10/09)
       *Levixa - Health Care Professional Letter (11/09)
       *Norvir - Health Care Provider Letter (2/10)
       *Norvir - Patient FAQ (2/10) 
       *ULTRAM - Health Professional Letter (5/10) 
      *FDA Consumer Health Information (6/10)
      *FDA Alert Bulletin - Benadryl Topical Gel (6/10)
      *FDA Alert Bulletin - Proton Pump Inhibitors (6/10)
• Children’s Assessment
• Intake Service Plan
• Service Plan
• Case Conference
• Case Closure
• Consent for CFP Participation
• Joint Case Management Service Plan
• Medical Information Request Form
• Individual Crisis Plan
• Authorization for the Release of Medical Information and
  Confidential HIV-Related Information Form - English
  (DOH-2557 rev. 8/05)
• Authorization for the Release of Medical Information and
  Confidential HIV-Related Information Form - Spanish
  (DOH-2557ES, rev. 8/05)
• Assessment Cover Sheet
• CMCM Provider MAP forms
• Collateral Assessment

• Supervisory Review Form
• Event Tracking Form
• Client Services Review Form
• Program Review Operations
• Consumer Survey

New Treatment Adherence Case Manager/Supervisor Position

• Background: Creation of the Treatment Adherence Case Manager/Supervisor Position
• Qualifications and Position Description
• Request to Add Treatment Adherence Case Manager/Supervisor Position

Fiscal/Program Reporting 

• Quarterly Fiscal Report
• Quarterly Report Instructions
• Cost Report
• Cost Report Certification Signoff
• Cost Report Instructions

COBRA 2010 Work Plan

• Program Information Form
• COBRA Work Plan 2010
• COBRA Budget 2010
• COBRA Budget Instruction 2010
• CCM/Supervisor Request
• Treatment Adherence CM/Supervisor Request

• Training Log
• Policy and Procedures Manual Outline
• Clinical Case Management Supervisor Position Description

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