QA Forms and Documentation

Notification of Beneficiary Rights / HIPAA / Beneficiary / Advance Directive / Peer Review / Documentation Standards / Site Certification / Provider Credentialing

To order Informing Materials please contact the QA's Informing Materials Desk at (510)567-8233 or email qainformingmaterials@acbhcs.org.


Notification of Beneficiary Rights How to Use the Packet: Informing Materials(6/10)* This document contains important information for 1st-time users! Informing Material Packet: Your Rights and Responsibilities - Spanish, Chinese, Farsi, and Vietnamese. Braille Available Upon Request. Consent for Services Freedom of Choice Confidentiality and Privacy Statement(Duty to Report) Advance Directive Information Beneficiary Problem Resolution Information Notice of Privacy Practices(HIPAA) Maintaining a Welcoming and Safe Place (not a required informing material) Notice of Privacy Practices Beneficiary Problem Resolution Information Memo from Marye Thomas, M.D.- Director of ACBHCS- 5/20/10 Notification of Beneficiary Rights Policy- NEW, 5/10 Copies Available Upon Request translated phrase in the five threshold languages HIPAA Breach Reporting Policy and Procedure 6-2012 Attachment 1- HIPAA Breach Risk Assessment Attachment 2- Federal Trade Commission Breach Reporting Form 2010 Memo from Marye Thomas, M.D.- Director of ACBHCS 2009 Notice of Privacy Practices Update, rescinded 5/10/10 2003 Notice to Providers RE: HIPAA Authorization to Disclose Individually Identifiable Health Information (IIHI) (Sample Form) For related Informing Materials, please see the Informing Materials page. Beneficiary Consumer Grievance and Appeal Process, revised 2/2010 Consumer and Family Grievance/ Appeal Form, Spanish, Chinese, Farsi & Vietnamese. Braille Available Upon Request. Sentinel Event/Death Reporting Form Advance Directive “Your Right to Make Decisions About Medical Treatment” Booklet, includes Five Threshold Languages. Braille Available Upon Request. “Your Right to Make Decisions About Medical Treatment”- English Handout Advance Directive Policy, revised 6/10 For related Informing Materials, please see the Informing Materials page. Peer Review Policy & Procedure FAQ Report Format Documentation Standards QA Memorandum Regarding Progress Notes Mental Health Plan(MHP) Provider Network Documentation Standards Manual RCR Form (Request for Concurrent Service Review) RES Form (Request For Extended Service Review) RCR Form (Request for Concurrent Service Review) RES Form (Request For Extended Service Review) Memo - QA Manual Documentation Standards & QA Update Clinical Record Documentation Standards - New 12/22/10 Audit Tool - Regulatory Compliance updated 04/2012 Standard Abbreviations Medi-Cal Updates May 2010 Provider Credentialing Policy, revised 2/2010 Professional Licensing Waiver Policy and Procedure, NEW 6-2012