This is a list for Alameda County BHCS providers to ensure that the appropriate informing materials are available to Medi-Cal beneficiaries, as required by the California Department of Health Care Services.
- Initial Forms that Must be in the Chart & Signed by Beneficiaries at Intake
- Signature page from the packet:
Informing Materials – Your Rights and Responsibilities (available in
Chinese Traditional,
Farsi,
Spanish,
Vietnamese,
Chinese Simplified,
Korean &
Tagalog).
This packet must be offered to Medi-Cal beneficiaries at intake, annually thereafter, and upon request.
The packet contains:
- Consent for Services
- Freedom of Choice
- Explanation of the three (3) items noted in B. & C. (below): Provider Referral List, Guide to Medi-Cal Mental Health Services & BHP Member Handbook
- Confidentiality & Privacy statement (Duty to Report)
- Advance Directive Information
- Beneficiary Problem Resolution Information
- Maintaining a Welcoming & Safe Place (not a required informing material)
- Notice of Privacy Practices (HIPAA/HITECH)
- Written Policy regarding Confidentiality of Records (provider policy)
- Releases of Information, as necessary (provider form)
- Things You Must Offer Beneficiaries to Review
These documents must be offered to new beneficiaries and be available in a lobby or area where they have access to them, without having to make a request. If desired, you may make a binder for these documents and label it, “Copies available upon request.” As a courtesy, that phrase is translated into the seven threshold languages for printing as a label:
- Provider Directory of all Alameda County Behavioral Health services (updated monthly in English and all threshold languages).
- For Mental Health Providers: Guide to Medi-Cal Mental Health Services - available in English, Spanish, Chinese Traditional, Farsi, Chinese Simplified, Vietnamese, Korean and Tagalog. Audio CD upon request.
- For Substance Use Treatment Providers: Guide to Drug Medi-Cal Services - available in English, Spanish, Chinese Traditional, Farsi, Chinese Simplified, Vietnamese, Korean and Tagalog. Audio CD upon request.
- Things that Must be Available in Your Lobby/Office
- Consumer & Family Grievance and Appeals Poster (must be posted)
- Consumer & Family Grievance/Appeal Form available in
English,
Spanish,
Chinese Traditional,
Farsi,
Simplified Chinese,
Vietnamese,
Tagalog & Korean with envelopes addressed to BHCS. Audio files are available here on our public grievance page.
To replenish your supply of the above materials, visit QA’s Informing Materials Page on the Provider website BHCS Providers Website. For materials not available on the website, email the BHCS Quality Assurance informing materials desk at qainformingmaterials@acbhcs.org, or call (510) 567-8233.
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