Informing Materials

Informing Materials List   

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 English, Spanish, Chinese, Farsi & Vietnamese). Braille available upon request.
   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. 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 five threshold languages for printing as a label; it is available at the website below, as are the following materials:

1. Provider Referral List, for Alameda County Behavioral Health Care Services (updated quarterly).
2. Guide to Medi-Cal Mental Health Services (available in English, Spanish, Chinese, Farsi, & Vietnamese) Braille is available upon request.


3. Things that Must be Available in Your Lobby/Office
1. Complaint Poster (must be posted)
2. Behavioral Health Plan Member Handbook – maroon pamphlet (available in 8 languages: English, Spanish, Chinese, Farsi, Vietnamese, Cambodian, Laotian, & Korean). Providers must have this pamphlet available in all 8 languages, even though a provider may not currently serve beneficiaries who speak those languages. Braille & CD versions are available upon request.
3. Consumer & Family Grievance/Appeal Form (available in English, Spanish, Chinese, Farsi & Vietnamese) with envelopes addressed to BHCS. Braille is available upon request.