Medi-Cal Informing Materials

Featured Materials

Client Rights & Grievance/Appeal Process and Form
English | Spanish (PDF: 786 and 789 kB)

Request for Change of Service Provider
English | Spanish (PDF: 766 and 374 kB)

MHS 112-1 NOABD Service Denial Notice
English | Spanish(PDF: 856 and 879 kB)

MHS 112-3 NOABD Delivery System Notice
English (PDF: 859 kB)

MHS 112-4 NOABD Modification Notice
English (PDF: 886 kB)

MHS 112-5 NOABD Termination Notice
English | Spanish(PDF: 838 and 882 kB)

MHS 112-6 NOABD Authorization Delay Notice
English | Spanish(PDF: 833 and 868 kB)

MHS 112-7 NOABD Timely Access Notice
English | Spanish(PDF: 825 and 860 kB)

MHS 112-8 NOABD Financial Liability Notice
English (PDF: 834 kB)

MHS 168 Beneficiary Request for Service Authorization
English (PDF: 260 kB)

These documents are given to clients receiving specialty mental health services that are covered by Medi-Cal.

	Beneficiary Handbook UPDATE AVAILABLE MARCH 10TH, 2023 English \| Spanish (PDF: 1.64 and 1.27 MB) Large type: English \| Spanish (PDF: 1.63 and 2.01 MB) (Print on 8.5" x 14" white paper)
	Client Rights Flyer English \| Spanish (PDF: 102 and 27 kB) (Print on 8.5" x 14" paper)
	Client Rights & Grievance/Appeal Process and Form English \| Spanish (PDF: 786 and 789 kB) Large type: English \| Spanish (PDF: 785 and 591 kB) (Print on 8.5" x 14" white paper)
	Consumer Notification of Licensing Boards English/Spanish (PDF: 80 kB) (Print on 8.5" x 11" paper)
	Early & Periodic Screening & Diagnosis Including Therapeutic Behavioral Services English \| Spanish (PDF: 670 and 608 kB) (Print on 8.5" x 11" white paper)
	Family Feedback Flyer English \| Spanish (PDF: 93 and 118 kB) (Print on 8.5" x 11" paper)
	Family Feedback Form - Adult Services English \| Spanish (PDF: 126 kB) (Print on 8.5" x 11" paper)
	Family Feedback Form- Children's Services English \| Spanish (PDF: 142 kB) (Print on 8.5" x 11" paper)
	Free Language Assistance Services English/Spanish (PDF: 48 kB) (Print on 8.5" x 11" paper)
	Point to Your Language Poster English/Spanish (PDF: 116 kB) (Print on 11" x 17" paper)
	Provider Directory for Specialty Mental Health Services - June 2023 (Updated Monthly) English - June 2023 \| Spanish - Junio 2023 (PDF: 994 kB & 1 MB)
	Provider Directory for Substance Use Treatment Services - April 2023 (Updated Monthly) English - April 2023 \| Spanish - Abril 2023 (PDF: 176 kB & 184 kB)
	Your Right to Make Decisions About Medical Treatment English \| Spanish (PDF: 459 and 573 kB) (Print on 14" x 8.5" paper)
	Beneficiary Non-Discrimination Notice English \| Spanish (PDF: 141 and 130 kB) (Print on 8.5" x 11" paper)

Privacy Practices

Attention contractors: You are required by law to provide clients with your own HIPAA Notice of Privacy Practices statement.

Attention clients: these are the County Mental Health Services Notice of Privacy Practices statements.

Notice of Privacy Practices for Health Care Clients
Print version: English | Spanish (PDF: 193 and 122 kB)

Form: Acknowledgement of Receipt of Notice of Privacy Practices
English | Spanish (PDF: 34.8 kB)

Mental Health Hotlines

	Beneficiary Handbook UPDATE AVAILABLE MARCH 10TH, 2023 English \| Spanish (PDF: 1.64 and 1.27 MB) Large type: English \| Spanish (PDF: 1.63 and 2.01 MB) (Print on 8.5" x 14" white paper)
	Client Rights Flyer English \| Spanish (PDF: 102 and 27 kB) (Print on 8.5" x 14" paper)
	Client Rights & Grievance/Appeal Process and Form English \| Spanish (PDF: 786 and 789 kB) Large type: English \| Spanish (PDF: 785 and 591 kB) (Print on 8.5" x 14" white paper)
	Consumer Notification of Licensing Boards English/Spanish (PDF: 80 kB) (Print on 8.5" x 11" paper)
	Early & Periodic Screening & Diagnosis Including Therapeutic Behavioral Services English \| Spanish (PDF: 670 and 608 kB) (Print on 8.5" x 11" white paper)
	Family Feedback Flyer English \| Spanish (PDF: 93 and 118 kB) (Print on 8.5" x 11" paper)
	Family Feedback Form - Adult Services English \| Spanish (PDF: 126 kB) (Print on 8.5" x 11" paper)
	Family Feedback Form- Children's Services English \| Spanish (PDF: 142 kB) (Print on 8.5" x 11" paper)
	Free Language Assistance Services English/Spanish (PDF: 48 kB) (Print on 8.5" x 11" paper)
	Point to Your Language Poster English/Spanish (PDF: 116 kB) (Print on 11" x 17" paper)
	Provider Directory for Specialty Mental Health Services - June 2023 (Updated Monthly) English - June 2023 \| Spanish - Junio 2023 (PDF: 994 kB & 1 MB)
	Provider Directory for Substance Use Treatment Services - April 2023 (Updated Monthly) English - April 2023 \| Spanish - Abril 2023 (PDF: 176 kB & 184 kB)
	Your Right to Make Decisions About Medical Treatment English \| Spanish (PDF: 459 and 573 kB) (Print on 14" x 8.5" paper)
	Beneficiary Non-Discrimination Notice English \| Spanish (PDF: 141 and 130 kB) (Print on 8.5" x 11" paper)

Medi-Cal Informing Materials

Featured Materials

Privacy Practices

Mental Health Hotlines

24-hour Access Line

24-hour Suicide Prevention

24-Hour Crisis Services