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 Action (see the Action 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 60 days, with the option of a 14 day extension if extending the deadline will be in your best interest. For questions, call (909) 386-8256.

Grievance Form/ Formulario de Quejas

Mail the form:
DBH Access & Referral
303 E. Vanderbilt Way
San Bernardino, CA 92415

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

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 “Action” taken by the County’s Mental Health Plan. An “Action” is defined as:

  1. Denial, or limiting, of an authorization of a requested service, including the type or level of service;
  2. Reducing, suspending, or terminating a previously authorized service;
  3. Denial, in whole or in part, of payment for a service;
  4. Failing to provide services in a timely manner, as determined by the Mental Health Plan or;
  5. Failing to act within the time frames for disposition of standard Grievances, the resolution of standard Action Appeals, or the resolution of expedited Action Appeals.

Appeal Form

An appeal is an oral or written request for review of an Action (as defined). An oral appeal must be followed up in writing. Action Appeal Forms are available below, in the waiting room of the clinic, or the Fee-For-Service Provider. Standard appeals are processed within 45 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 3 working days. For questions call (909) 386-8256.

Action Appeal Form / Formulario de Acciόn de Apelaciόn

Mail the form to:
DBH Access & Referral
303 E. Vanderbilt Way
San Bernardino, CA 92415

The Mental Health Plan (MHP) will provide a second opinion by a licensed mental health professional employed by, contracting with or otherwise made available by the MHP when the MHP or its providers determine that the medical necessity criteria have not been met and that the beneficiary is, therefore, not entitled to any specialty mental health services from the MHP. The MHP shall determine whether the second opinion requires a face-to-face encounter with the beneficiary.

Request for Second Opinion Form / Petición de Una Segunda Opinion

After the appeals process is exhausted you may file for a State Fair Hearing if you are not satisfied with the outcome of the appeal process. In most cases you have 90 days to ask for a hearing. You may verbally or in writing file for a State Fair Hearing after the exhaustion of an Action Appeal or Expedited Action Appeal process, whether or not you have received a Notice of Action.

Please review the following brochure for more information on how to file a state fair hearing request: State Fair Hearing Rights Poster

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