Informing Materials

The information below is to be used by ACBHD Specialty Mental Health Services (SMHS) and Drug Medi-Cal Organized Delivery System (DMC-ODS) providers to ensure that the documents required by the California Department of Health Care Services (DHCS) are made available to Medi-Cal members per regulations. ^[1]

Alternative formats, for example Braille or audio versions of Informing Materials may be requested from the ACBHD QA department by emailing: QAIM@acgov.org.

In the sections below, the term member refers to individuals seeking treatment or their authorized representatives.

^[1] CCR, Title 9, Section 1810.360 (b) (3), (d) and (e) and Cal. Code Regs. Tit. 9, § 1850.205 - General Provisions

Documents that must be reviewed and offered to members

The documents in this section must be reviewed and offered to members 1) At intake, 2) When there is a substantial change to the content and 3) Upon request.

The Acknowledgement of Receipt page must be completed and signed by the member, acknowledging that the packet has been reviewed, or re-reviewed, with them and providing their consent to receive voluntary services.

1. ACBHD Informing Materials Packet
   • The ACBHD Informing Materials packet is integrated for SMHS and DMC-ODS and is available in standard and large format in all threshold languages:
   
   
   • Standard Format: Revisions posted January 2025
   • Large Format: Large Format Forthcoming
   
   
   • Providers are required to use the ACBHD Informing Materials packet. Additional information may be added, and the format may be altered to meet agency needs. However, ACBHD’s content may not be removed, altered or contradicted.

   The packet contains the following information:

   • A message to Service Providers
   • Welcome to Alameda County Behavioral Health Plan
   • Freedom of Choice
   • Notice of Non-Discrimination
   • Consent for Services
   • Treatment Services and Providers of Care
   • Maintaining a Welcoming and Safe Place
   • Member Handbook
   • Provider Directory
   • Problem Resolution
   • Advance Directives
   • Confidentiality and Privacy
   • Notice of Privacy Practices
   • 42 CFR Part 2: Privacy of Drug and Alcohol Treatment Services
   • Acknowledgement of Receipt
2. Advance Directive Educational Material

   As part of the requirement to educate members about Advance Directives, a copy of the “Your Right to Make Decisions About Medical Treatment” document should be provided to members in the language and format of their choice:

   • Standard Format
3. ACBHD Informing Materials Acknowledgement of Receipt
   • Following review of the ACBHD Informing Materials packet with the member, the “Acknowledgement of Receipt” page must be signed and dated by the member. The signed document should be retained in the member’s clinical record and provided to ACBHD and/or DCHS upon request.
     
     
     • Acknowledgement of Receipt- English, Spanish, Arabic, Farsi, Simplified Chinese, Traditional Chinese, Korean, Tagalog, Vietnamese
     
     
   • In case of a substantial change to the content, the changes must be reviewed with the member and a new signature and date obtained and saved in the member’s clinical record.
4. ACBHD Provider Directory
   • The Provider Directory, containing information about all Alameda County Behavioral Health Department services, is available in English and all threshold languages on the ACBHD Public website. The Directory must be reviewed with the member electronically, and if requested, be provided as a paper copy.
   
   
   • There is no requirement for providers to maintain paper copies of the Provider Directory onsite. However, providers are required to have the capability to electronically access these documents to print for members in their preferred language, and for ACBHD reviewers, upon request. Instructions for printing the ACBHD Provider Directory can be accessed here: Printing ACBHD Provider Directory
   
   
   • If not maintaining paper copies onsite, the following document must be posted in a visible and accessible area of the office/lobby: Copies available upon request.
   
   
   • If requested, paper copies must be provided to members free of charge, within 5 business days of request.


5. Integrated Member Handbook
   • Handbooks are integrated for SMHS and DMC-ODS and are available in standard and large format in all threshold languages:
   
   
   • Standard Format - January 2025: English, Spanish, Arabic, Chinese Traditional, Chinese Simplified, Farsi, Vietnamese, Korean and Tagalog.
   • Large Format - January 2025: English, Spanish, Arabic, Chinese Traditional, Chinese Simplified, Farsi, Vietnamese, Korean and Tagalog.
   
   
   • The content of the Member Handbook may not be altered.
   
   
   • There is no requirement for providers to maintain paper copies of the Member Handbook onsite. However, providers are required to have the capability to electronically access the Member Handbook to print for members in their preferred language, and for ACBHD reviewers, upon request.
   
   
   • If not maintaining paper copies onsite, the following document must be posted in a visible and accessible area of your office/lobby: Copies available upon request.
   
   
   • If requested, paper copies must be provided to members free of charge, within 5 business days of request.
   
   
6. Other Consent Forms, As Applicable
   • Documentation of Telehealth Consent: See section 7 of the QA Manual for requirements and optional consent forms in all threshold languages.
   
   
   • Documentation of Medication Consent: See section 7 of the QA Manual for requirements.
   
   
   • Release of Information forms: See section 11 of the QA Manual for forms and additional information.
   
   
   • All signed consent forms should be retained in the member’s clinical record and provided to ACBHD and/or DHCS, upon request.
   
   

Documents that must be visible and accessible in the provider’s lobby or office

The following documents must be visible in the provider’s lobby or office and accessible without the member having to ask for them.

1. Posters
   1. Grievance and Appeal Poster
   
   
   • The poster includes information in all threshold languages.
   • It instructs members to obtain the Grievance and Appeal Request form and ACBHD-addressed envelopes from their provider.
   
   
   2. Language Assistance Poster
      
      
      • This poster notifies members of their right to be provided with information in their language of choice.
      
      

      Posters and ACBHD-addressed envelopes may be requested here.

2. Grievance and Appeal Process and Forms
   • The document describing the grievance and appeal process and including the relevant forms is available in all threshold languages:
     
     
     • Standard Format – June 2025:
     English, Spanish, Arabic, Simplified Chinese, Chinese Traditional, Farsi, Korean, Vietnamese, and Tagalog
     
     
     • Large Format - June 2025:
     Large Format Forthcoming
     
     
3. Notice of Significant Change
   • A notice regarding any significant change, as defined by DHCS, to member materials must be posted at least 30 days prior to the effective date of the change.
   
   
   • ACBHD will alert providers of any significant changes to member materials and the required notice will be posted in this section for use by providers.
   
   
   • Notice of Significant Change - November 2024

   English, Spanish, Arabic, Chinese Simplified, Chinese, Traditional, Korean, Farsi, Vietnamese, and Tagalog