Informing Materials List

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

   

Informing Materials List   

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. [1]
  1. Initial Forms that Must be in the Chart & Signed by Beneficiaries at Intake
    1. Signature page from the packet: Informing Materials – Your Rights and Responsibilities (available in Arabic, Chinese Traditional, Chinese Simplified, Farsi, Korean, Spanish, Tagalog & Vietnamese).

      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)

    2. Written Policy regarding Confidentiality of Records (provider policy)
    3. Releases of Information, as necessary (provider form)

  2. Documents You Must Offer Beneficiaries to Review
    3. The documents below must be offered to beneficiaries when they begin receiving a specialty mental health service and upon request. Upon request, Providers must provide a hard copy (paper form) of this informational document within 5 business days, free of cost.[2] Providers are not required to maintain a supply of these documents onsite, however, this notice, “Copies available upon request,” can be posted for beneficiaries in a visible and accessible area of the office or lobby.

    1. Provider Directory[3] of all Alameda County Behavioral Health services (in English and all threshold languages).

    2. Integrated Member Handbook:


    3. Documents You Must Make Available in Your Lobby/Office
      1. Consumer & Family Grievance and Appeals Poster email the BHCS Quality Assurance Informing materials desk at QAIM@acgov.org, or call (510) 567-8233 to request copies.

      2. Consumer & Family Grievance/Appeal Forms available in English, Spanish, Arabic, Simplified Chinese, Chinese Traditional, Farsi, Korean, Vietnamese, and Tagalog with envelopes addressed to ACBH. An audio CD is available upon request; Audio formats are also available on ACBH’s public webpage: File A Grievance (Client/Patient Only) – Alameda County Behavioral Health (acbhcs.org)

      3. Consumer Notice: Beneficiary Handbook Consumer Notice - available in English | Arabic | Chinese Simplified | Chinese Traditional | Korean | Farsi | Spanish | Tagalog | Vietnamese


    Footnotes

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

    [2] 42 CFR § 438.10 - Information requirements.

    [3] Please click here for instructions on how to print the ACBH Provider Directory.