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:
Written Policy regarding Confidentiality of Records (provider policy)
Releases of Information, as necessary (provider form)
- 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)
Documents You Must Offer Beneficiaries to Review
The documents below must be offered to beneficiaries when they first receive a specialty mental health service AND upon request. Providers are not required to maintain current copies of these documents onsite. Rather, providers can simply have a notice posted onsite, written in English and the threshold languages, that indicates “Copies available upon request.” The notice must 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, Spanish, Arabic, Chinese Traditional, Farsi, Chinese Simplified, Vietnamese, Korean and Tagalog. Audio CD upon request. (Note: The Guide is also known as the Beneficiary Handbook)
- For Substance Use Treatment Providers: Guide to Drug Medi-Cal Services - available in English, Spanish, Arabic, Chinese Traditional, Farsi, Chinese Simplified, Vietnamese, Korean and Tagalog. Audio CD upon request. (Note: The Guide is also known as the Beneficiary Handbook).
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 Expectation Change.
Documents You Must Make Available in Your Lobby/Office
The following documents must be posted for beneficiaries in a visible and accessible area of the office or lobby without having to make a request:
- Consumer & Family Grievance and Appeals Poster: Email QAIM@acgov.org for an electronic poster. We do not send out physical posters.
- Consumer & Family Grievance/Appeal Forms available in English,
Tagalog with envelopes addressed to BHCS. Audio files are available here on our public grievance page.
- Beneficiary Handbook Consumer Notice (Note: Translations forthcoming): Beneficiary Handbook Consumer Notice - available in English
- To replenish your supply of the above materials, visit QA’s Informing Materials Page. To request a digital version the Grievance and Appeals poster, email the ACBH Quality Assurance Informing Materials desk at QAIM@acgov.org, or call (510) 567-8233. We can only provide electronic versions.
 CCR, Title 9, Section 1810.360 (b) (3), (d) and (e) and Cal. Code Regs. Tit. 9, § 1850.205 - General Provisions
 Please click here for instructions on how to print the ACBH Provider Directory.