Forms For Clients

24 Hour
Crisis Response and
Service Access Line

If the crisis places anyone in immediate danger, call 911.
If the crisis does not involve immediate danger, and if the person in crisis has insurance coverage through a health plan, call the health plan to get a referral to a covered mental health provider.
For all others, call the 24-hour toll-free Access Line at (888) 868-1649. Someone is available to assist you 24 hours per day, seven days per week.

(888) 868-1649

For medical emergencies, call 911

Línea de Acceso para Servicios y Crisis, Gratuito y Disponible las 24 Horas del Día.

Si la crisis pone en peligro inmediato a cualquier persona, llame al 911.
Si la crisis no implica peligro inmediato y si la persona en crisis tiene cobertura de seguro mediante un plan de salud, llame al plan de salud para que lo refieran a un proveedor de salud mental apropiado.
Para las otras situaciones, llame a la línea de acceso gratuito de Behavioral Wellness al (888) 868-1649. La llamada es gratuita y cuenta con asistencia de operadores las 24 horas del día, los 7 días de la semana.

(888) 868-1649

Para emergencias médicas, llame al 911

Provider Portal

Additional Hotlines

This is the Alert block.

Forms for Clients

Behavioral Wellness Appeal Form English | Spanish
Behavioral Wellness Grievance Form English | Spanish
Request for Change of Care Provider/ Clinician (English)
Request for Change of Care Provider/ Clinician (Spanish)
State Fair Hearing Information English | Spanish
Drug Medi-Cal State Fair Hearing Information (English)
ROI - Consent for Release of Patient Information or Records English | Spanish
Request a Second Opinion English | Spanish
Advance Directives for Medical and/or Psychiatric Healthcare English | Spanish
Application to Serve as a Voting Member, Consumer and Family Member Advisory Committee (English and Spanish)

Also see:

HIPAA Information | Beneficiary Information | Patients' Rights

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