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 following documents must be offered to beneficiaries when they first receive a specialty mental health service AND upon request. Providers can simply have a notice 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. Thus, providers are not required to maintain current copies of these documents onsite:
- 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.
- 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.
- Beneficiary Handbook Consumer Notice (Note: Translations forthcoming): Beneficiary Handbook Consumer Notice - available in English
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
- Consumer & Family Grievance/Appeal Forms available in English, Spanish, Arabic, Simplified Chinese, Chinese Traditional, Farsi, Korean, Vietnamese, and Tagalog with envelopes addressed to BHCS. Audio files are available here on our public grievance page.
To replenish your supply of the above materials, visit QA’s Informing Materials Page on the Provider website BHCS Providers Website. To request the Grievance and Appeals poster (it should not be printed), email the ACBH Quality Assurance informing materials desk at firstname.lastname@example.org, or call (510) 567-8233.
 CCR, Title 9, Section 1810.360 (b) (3), (d) and (e) and CCR Title 9, Section 1850.205 (c)(1)(C)
 However, for Community Based Organizations (CBOs), hard copies of these documents must be available onsite when site visits are conducted by ACBH.
 Please click here for instructions on how to print the ACBH Provider Directory. (updated 9/19/2022)