Informing Materials

Initial Forms that Must be in the Chart & Signed by the Consumer   

• Advance Directive (Adults only)
• Beneficiary Problem Resolution Information (Form) - English, Spanish, Chinese, Farsi & Vietnamese
• Notice of Privacy Practices (Information & Form) - English, Spanish, Chinese, Farsi & Vietnamese
  (pg. 8 needs to be signed and witnessed; pg 1-7 is to be given to the consumer)
• Limits of Confidentiality (Duty to Report)
• Consent for Treatment
• Written Policy regarding Confidentiality of Records
• Releases of Information as necessary

Documents You Must Offer Your Consumers  

If you wish, you may make a binder for these and label it, “Copies available upon request”. The binder would then have to be left in the lobby where consumers would have free access to it.

Both of these documents are available on the website

• Provider Referral List
• Guide to Medi-Cal Mental Health Services - English , Chinese, Farsi, Spanish & Vietnamese

Documents that Must be Available in Your Lobby/Office   

• Complaint Poster (Must be posted.  To get posters, please contact QA Office at (510) 567-8105)
• Behavioral Health Plan Member Handbook (maroon pamphlet) - English, Spanish, Chinese, Farsi, Vietnamese, Lao, Cambodian & Korean
• Consumer Complaint Form