LOS ANGELES COUNTY
DEPARTMENT OF MENTAL HEALTH
  Policy 200.05 Request for Change of Provider
 
  PROCEDURES
  1. Staff shall provide the Request for Change of Provider form to beneficiaries requesting a program of service and/or practitioner change.
     
    1. Programs of service shall have Request for Change of Provider forms available or provide beneficiaries with the address to directly download it from the DMH website.
       
    2. Staff or Patients' Rights Office (PRO) Advocates shall provide beneficiaries assistance with completing the Request for Change of Provider form when requested.
       
    3. Clinic staff providing services to the beneficiary shall receive the completed Request for Change of Provider form from the beneficiary.
       
    4. Clinic staff shall sign Request for Change of Provider forms upon receipt and provide beneficiaries with a copy.
       
  2. Program managers shall attempt to accommodate all beneficiary requests to change the program of service and/or practitioner.
     
    1. The beneficiary is under no obligation to provide any reasons for their request to change the program of service location or practitioner. In order to improve the quality of programs and understand the nature of the request, program managers shall attempt to obtain information regarding the request from the beneficiary. The program of service shall attempt to clarify any misunderstanding or resolve a concern at a level that is satisfactory to the beneficiary. The beneficiary may, at this time or any other, rescind the request.
       
    2. Program managers may not be able to accommodate a beneficiary with a change of provider. Program managers shall document the reasons (e.g., frequent requests, repeated requests, or insufficient number of practitioners).
       
  3. Within 10 working days of receiving a Request for Change of Provider form, the program manager shall verbally notify the beneficiary of the outcome followed by the appropriate written confirmation.
     
    1. The appropriate written confirmation of notification shall be maintained in a separate administrative file and retained for 10 years.
       
    2. If the beneficiary is not satisfied with the outcome of the request, they may pursue the Beneficiary Problem Resolution process as defined in Policy 200.04 and file a grievance with PRO.
       
  4. Staff shall direct a beneficiary requesting to change a program of service to contact PRO.
     
    1. Within 10 working days of receiving the request, PRO shall provide the beneficiary with names of alternative programs of service in the area of choice.
       
    2. Providers shall maintain Request for Change of Provider forms received from beneficiaries for 10 years.
       
  5. The Program Manager shall collect all submitted Request for Change of Provider forms at the end of each workday and maintain them in a separate administrative file.
     
    1. Program managers shall retain all Request for Change of Provider forms for 10 years.
       
    2. The Quality Improvement unit shall review all Request for Change of Provider forms to determine if there are any trends.
       
    3. Program managers or designees shall enter the information collected on Request for Change of Provider forms into the Public Facing Request for Change of Provider Database (PFCOP) by the 10th day of every month noting also if there are no requests or as directed by PRO.