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
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)
Documents You Must Offer Beneficiaries to Review
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.
Providers are not required to maintain a supply of these documents onsite, however, this notice, “Copies available upon request,” shall can be posted for beneficiaries in a
visible and accessible area of the office or lobby.
- Provider Directory of all Alameda County Behavioral Health services (in English and all threshold languages).
- For Mental Health Providers: Guide to Medi-Cal Mental Health Services - available in English,
An audio CD upon request; Audio formats are also available on ACBH’s public webpage: Beneficiary Handbook – Alameda County Behavioral Health (acbhcs.org)
- For Substance Use Disorder Providers: Guide to Drug Medi-Cal Services - available in English,
Audio CD upon request.
NOTE: As of January 23, 2023, ACBH is no longer requiring providers to
have hard copies of the Provider Directory and the Guide to Medi-Cal
Mental Health Services during on-site visits. ACBH now requires providers
to have the capability to electronically access these documents for
beneficiaries and ACBH staff, upon request. For more information on this
change, please see Site Certification Provider Memo RE: Onsite Visit
Documents You Must Make Available in Your Lobby/Office
- 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.
- Consumer & Family Grievance/Appeal Forms available in English,
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)
- Consumer Notice:
Beneficiary Handbook Consumer Notice - available in English |
Chinese Simplified |
Chinese Traditional |
 CCR, Title 9, Section 1810.360 (b) (3), (d) and (e) and Cal. Code Regs. Tit. 9, § 1850.205 - General Provisions
 42 CFR § 438.10 - Information requirements.
 Please click here for instructions on how to print the ACBH Provider Directory.