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Client Section

South Coast Community Services

(877) 527-7227 Phone | www.southcoastcs.org

Department of Behavioral Health

SIMON #: (For Office Use Only)

Change of Provider Request Form – Page 1

If you believe that your current provider is not meeting your treatment needs and would like to request a change in provider, please fill out this form and return to the receptionist at the clinic where you are receiving services. Requesting a change of provider does not put you at risk of being denied behavioral health services or having the type of services you are receiving change.

Requests for change of provider will be reviewed carefully by the clinic supervisor and approved, as appropriate. You will be informed of the outcome of your request by letter or phone call.

You can get help with filling out this form from a clinic staff member at the location where you are receiving services, from the ACCESS Unit at (888) 743-1478, or from the Patients’ Rights Office at (800) 421-4657.

Date of Request

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Month

Day

Year

Client Name*

First Name*

Last Name*

Date of Birth*

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Month

Day

Year

Mobile Phone Number*

Guardian Section:

Client is a minor Client is a conservatee N/A

Guardian Name*

First Name*

Last Name*

1. Current provider*

2. Why are you asking to change your provider?

Communication (e.g. doesn’t listen; doesn’t return calls; I don’t understand what they are saying) Cultural Issues (i.e. doesn’t understand my cultural background) Gender (i.e. requesting a specific gender) - Specify Gender Below: Language (i.e. requesting a specific language) - Specify Language Below: Medication Issues (e.g. side effects; need second opinion; need to change medication) Recommended (i.e. recommended by clinician or family) Request for a specific doctor/clinician - Specify Physician Below: Rude and/or unprofessional Scheduling concerns (e.g. delays in between appointments; long wait time in the lobby) Telemedicine/telehealth (i.e. requesting face-to-face treatment) Treatment concerns

Other: Other Value

Gender Requested

Language Requested

Physician Requested

3. What type of change do you want?*

4. Please describe your specific concerns*

Provider Section

Department of Behavioral Health

South Coast Community Services

(877) 527-7227 Phone | www.southcoastcs.org

SIMON #: (For Office Use Only)

Change of Provider Request Form – Page 2

**THIS SIDE IS FOR STAFF USE ONLY**

Name of Site:

Type of Provider

Case Manager Clinician Nurse/LVN/Psych Tech Psychiatrist Other

Current Services Provided:

Status

Approved Denied

Approval Information

New Provider Name:

Next Appointment Date:

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Month

Day

Year

Client Informed On:

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Month

Day

Year

Client informed Via:

Mail Phone Unable to Contact Client

Denial Information

Reason:

Client Informed on:

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Month

Day

Year

Client Informed Via:

Mail Phone Unable to Contact Client

Clinic Supervisor Information

Clinic Supervisor/Clinical Medical Director Name:

Clinic Supervisor/Clinic Medical Director Email List:

Date

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Month

Day

Year

NOTE: This form should be sent to the ACCESS UNIT at 303 E. Vanderbilt Way, San Bernardino, CA 92415-0026 by the 5th day of the month, following the date the request for change was made.

Client Section

South Coast Community Services

(877) 527-7227 Phone | www.southcoastcs.org

Provider Section

South Coast Community Services

(877) 527-7227 Phone | www.southcoastcs.org

© 2021 South Coast Community Services (R)