Consumer Forms
For questions on any of these forms or for assistance in completing them, call (909) 386-8256.
Click on the name or + sign to expand any form you wish to learn more about
As a DBH consumer, you have the right to request a change if you are not satisfied with your current service provider. Requesting a change of provider does not put you at risk of being denied behavioral health services or having the type of services you received changed. Please fill out the form and turn it into the receptionist at the clinic where you are currently receiving services:
Change of Provider Request Form/ Formulario para Solicitar el Cambio de Proveedor
Access Unit-
A grievance is an oral or written expression of your dissatisfaction about any matter other than an Adverse Benefit Determination (see the Appeal Process section for more information). You have the right to make a grievance about any aspect of your treatment at a clinic or by a Medi-Cal Fee-For-Service Provider (private psychiatrist, psychologist, LCSW, or LMFT). You may make a grievance verbally or in writing. Grievance forms are available below or in provider/clinic lobbies. Grievances will be processed within 90 Calendar days, with the option of a 14-calendar day extension if extending the deadline will be in your best interest. For questions, call 1 (888) 743-1478.
Grievance Form/ Formulario de Quejas
Mail the form:
DBH Access & Referral
303 E. Vanderbilt Way
San Bernardino, CA 92415
Grievance Posters
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Patients’ Rights-
A grievance is an oral or written expression of your dissatisfaction to inpatient and outpatient patients’ rights matters as referenced in the Patients’ Rights posters. Patients can submit a grievance over the phone or in writing.
To submit a verbal Patients’ Rights grievance, call (800) 440-2391. To submit a written Patients’ Rights grievance, complete a Patients’ Rights Grievance form located in a provider or clinic lobby or download the form here, and mail OR email the completed form to:
Patients’ Rights Office
850 E. Foothill Blvd.
Rialto, CA 92376
DBHPatientRightsOffi@dbh.sbcounty.gov
Grievances will be addressed within 24 hours by phone or letter. For additional questions, call (909) 421-4657.
You also have the right to appeal an Adverse Benefit Determination. An Adverse Benefit Determination is defined as the following actions taken by Department of Behavioral Health, contract agency, or Fee-For-Service Provider:
- Denial or limited authorization of requested service(s), including determinations based on the type or level of service(s), medical necessity, appropriateness, setting or effectiveness of a covered benefit;
- Reduction, suspension, or termination of a previously authorized service(s);
- Denial, in whole or in part, of payment for a service;
- Failure to provide services in a timely manner;
- Failure to act within the time frames for standard resolutions of Grievance and/or Appeal;
- Denial of a client or potential clients’ request to dispute financial liability.
Appeal Form
An appeal is an oral or written objection to an Adverse Benefit Determination requiring further consideration and review by Department of Behavioral Health. An appeal must be filed within sixty (60) calendar days from the date on the Notice of Adverse Benefit Determination. Action Appeal Forms are available below, in the waiting room of the clinic, or the Fee-For-Service Provider. Standard appeals are processed within 30 days, with the option of a 14-day extension if extending the deadline will be in your best interest. Expedited Action Appeals may be requested if you or your provider certifies that taking the time for a standard action appeal resolution could seriously jeopardize your life, health, or ability to attain, maintain, or regain maximum function. Expedited Appeals are processed within seventy-two (72) hours after the expedited appeal request is received. For questions call 1 (888)743-1478
Action Appeal Form / Formulario de Acciόn de Apelaciόn
Mail the form to:
DBH Access & Referral
303 E. Vanderbilt Way
San Bernardino, CA 92415
When requested, the Department of Behavioral Health will provide a second opinion by a licensed mental health professional within its network of care or will arrange for you to obtain a second opinion outside the DBH network when its providers determine that the medical necessity criteria have not been met and that the member is, therefore, not entitled to any specialty mental health services or drug Medi-Cal organized delivery system services.
Request for Second Opinion Form / Petición de Una Segunda Opinion
You may request a State Hearing verbally, as a written request or you may complete the online hearing request page after the exhaustion of the appeals process.
By phone: Call 1-800-952-5253. If you cannot speak or hear well, please call TTY/TDD 1-800-952-8349.
In writing: California Department of Social Services
State Hearing Division
P.O. Box 944243, Mail Station 9-17-37
Sacramento, CA 94244-2430
Electronically: You may request a State Hearing online. Please visit the California Department of Social Services’ website to complete the electronic form: Hearing Request. Please review the following brochure for more information on how to file a state fair hearing request: State Hearing Rights
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(English / Spanish/ Vietnamese / Mandarin)
You have the right to make healthcare decisions. You can plan now for your medical care needs if in the future you are unable to speak for yourself.
Advance Health Care Directive Brochure /Directiva Anticipada de Cuidado de Salud/ Advance Directive Brochure Vietnamese