BHS Health Center Network is a network of community clinics that provide low-cost health care on a sliding scale. Costs for patients are determined by a sliding fee scale that is calculated based on income and household size. We proudly serve all patients, regardless of inability to pay. The following information is required for each patient due to federal regulations. All information is confidential and protected. We appreciate your cooperation with these requirements. We are required to collect this information each year.

Patient Information

Detailed Information
As of today, are you homeless, staying in a shelter, temporary housing, transitional housing, residential treatment facility, doubling up, couch surfing, staying in a car or on the street, day-to-day occupancy, or staying in permanent supportive housing?

Health and Income Information

Pharmacy Information
Previous Physician
Parent/Guardian or Spouse Information
Emergency Contact Information

Instructions about the medical care you want to receive if you get very sick.

Instructions about who you want to make medical decisions for you if you are not able to make them).

Instructions about the medical care you want to receive if you get very sick.

Instructions about who you want to make medical decisions for you if you are not able to make them

Requirements to Register with BHS Health Center Network
  • Identification
    Acceptable forms of ID include: Driver’s License, California I.D., Passport, Green Card, School I.D., etc.
  • Your InsuranceCard
    There is NO FEE to register at the clinic. If you do not have any health/medical insurance coverage, please be prepared to pay by cash or check for each visit with the provider and for all labs. We can provide you with assistance to apply for programs to cover your health costs. If you have a co-pay, please be prepared to pay by cash, check, or credit for each visit with the provider and for all labs.

Informing Materials:

For all patients of BHS Health Center Network:

  • Consent for Treatment (48-001,04/2019)
  • Patient Bill of Rights (48-003,04/2019)
  • Patient’s Responsibilities (48-003,04/2019)
  • Grievance Procedure (48-004,04/2019)
  • HIPAA Notice of Privacy Practices (48-011,04/2019)
  • AdditionalConsents

Consent for Treatment

This consent applies to “you” the patient, either yourself or the patient for whom you are the parent or legally authorized representative. Medical care is a patient care service in response to a wide range of medical care needs of patients of all ages regardless of gender, color, race, creed, national origin or disability. The purpose of medical care is:

  • To treat disease, injury and disability by examination, testing and use of procedures as needed, in the aid of diagnosis ortreatment.
  • To obtain information needed in diagnosing and examiningpatients.
  • To prevent or minimize residual physical and mentaldisability.
  • To aid patients in achieving their maximum potential within theircapabilities.
  • To accelerate convalescence and reduce the length of the functionalrecovery.

You acknowledge that your medical care and treatment may be provided by a Medical Doctor, Mid- Level Practitioner, such as a Nurse Practitioner, a Physician’s Assistant or Health Professional Student under direct supervision of a Doctor; all referred to as a “provider” in this document. You are also aware that BHS Health Center Network does not provide emergency nor in-patient hospital services, although you can be referred to other providers of these services during regular clinic hours.

All procedures will be thoroughly explained to you before you are asked to perform them. You are expected to cooperate fully with the examination and stop any test or procedure before experiencing any increase in your current level of pain or discomfort. There are certain inherent risks with

medical care; if you have any concerns about your proposed treatment as described by your provider please let them know prior to the examination or procedure. The provider will take every precaution to ensure that you are protected from any potentially hazardous situation. You will never be forced to perform any procedure that you do not wish to perform. Based on the above information, you agree to cooperate fully and to participate in all medical care procedures and to comply with the plan of care as it is established. You hereby request and consent to diagnostic procedures, laboratory, and medical treatment by the professional staff of BHS Health Center Network.

If you are requesting HIV/STD services, you give permission to the staff of BHS Health Center Network to draw your blood or collect a urine sample. You understand that you have the option to be tested for Syphilis, Chlamydia, Trichomonas, Gonorrhea, Hepatitis B, Hepatitis C and Herpes. You have been informed of the tests that you have elected to take, and you are aware that if you test positive for any of these tests, your results and any contact information will be provided to the Los Angeles or Orange County Department of Health Services Public Health Program, the Office of Health Programs and Epidemiology and the Acute Communicable Disease Control Unit, in accordance with California code of regulation, title 17.

You acknowledge that BHS Health Center Network is an integrated care center, and grant accessto your treatment records, diagnosis information, attendance or billing records, and other client information to other physicians, primary care providers and other staff involved in providing your services. You further authorize BHS Health Center Network to release medical/social information to persons or agencies directly concerned with public health or community welfare and to private individuals professionally engaged in carrying out a treatment plan forme.

You further acknowledge that you are financially responsible and agree to pay for any servicesthat are not covered by your insurance, and to pay in full if you are notinsured.

You have received, read, and agreed to the attached terms and conditions of the “Registration Packet (04/2019)” and acknowledge that you have filled out the included information to the best of your abilities. You acknowledge that you have completely read, fully understand, and voluntarily agree to and accept this form. You have had the opportunity to discuss it, and your questions have been answered to your complete satisfaction.


  1. Receive high quality care based on professional standards of practice, regardless of his or her (or his or her family’s) ability to pay for such services. Care and services shall be freeof intellectual, emotional, physical, sexual, financial or psychological abuse, including humiliation, neglect or retaliation bystaff.
  2. Obtain services without discrimination on the basis of sex or gender identity, sexual orientation or preference, marital status, cultural or ethnic group identification,national origin, , socio-economic, educational or religious background, age, physical or mental disability, diagnosis/condition or the source of payment for yourcare.
  3. Receive considerate and respectful care, and be treated with courtesy by all staff, at all times, and in a manner that respects his/her privacy anddignity.
  4. Facilitate your own healthcare decisions, to accept or refuse medical treatment, and to make an advance health care directive. You have the right to designate a surrogate to make health care decision(s) should you become unable to doso.
  5. Know the name and qualifications of all individuals responsible for your care andbe informed on how to contact theseindividuals.
  6. Express your preference regarding your health provider and request a different provider if dissatisfied. BHS will consider your preferences and address as clinically appropriate and as staffing patternsallow.
  7. Receive a complete, accurate, easily understood and culturally and linguisticallycompetent explanation of (and, as necessary, other information regarding) any diagnosis, treatment prognosis and/or planned course of treatment, alternatives (including no treatment), and associated risks and benefits. You will be informed of any special treatment interventions and theirpurpose.
  8. Receive sufficient information, in sufficient time, so that you may actively and fully participate in decisions regarding your health care and to provide informed consent priorto any diagnostic or therapeutic procedure (except in emergencies). If a patient is unable to participate fully, he or she has the right to be represented by parents, guardians, family members or other designatedsurrogates.
  9. Refuse any treatment (except as prohibited by law) or concurrent services, and be informed of the alternatives and/or consequences of refusal, which may include the clinic having to inform the appropriate authorities of this decision, and to express preferences regarding any future treatment orservices.
  10. Be informed if any treatment is for research purposes or is experimental in nature, and be given the opportunity to provide informed consent before such research or experiment will begin (unless such consent is otherwise waived). You have the right to refuse participation or involvement in researchprojects.
  11. Confidentiality of your medical records and privacy in accordance with federal regulations (42 CFR part 2, and 45 CFR parts 160 -164). Detailed information about release of information and other privacy rights is included in the HIPAA Privacy Notice provided to you at intake, including your right to access your record.
  12. Ask questions (at any time before, during or after receiving services) regarding any diagnosis, treatment, prognosis and/or planned course of treatment, alternatives and risks, and receive understandable and clear answers to suchquestions.
  13. Obtain another medical opinion prior to any procedure and receive information regarding availability of support services, including legal, self-help, translation, transportation and educationservices.
  14. Request and receive information regarding his or her financial responsibility and receivean explanation of your bill, an itemized copy and description of charges to your insurance, regardless of the source ofpayment.
  15. Request any additional assistance necessary to understand and/or comply with theclinic’s administrative procedures and rules, access health care and related services, participate in treatments, or satisfy payment obligations by contacting the clinicmanager.
  16. Have all of these rights apply to the person who may have legal responsibility tomake decisions on your behalf regarding yourcare.
  17. File a grievance or complaint about the clinic or its staff without fear of discrimination or retaliation and have it resolved in a fair, efficient and timely manner. The Grievance Procedures and who to contact is provided to you atintake.
  18. Receive a copy of your rights atintake.


  1. Providing accurate personal, financial, insurance and medical information (including all current treatments and medications) prior to receiving services from the clinic and itshealth careproviders.
  2. Following all administrative and operational rules and procedures posted within thefacility.
  3. Behaving at all times in a polite, courteous, considerate and respectful manner to all clinic staff and patients, including respecting the privacy and dignity of otherpatients.
  4. Supervising his or her children while at theclinic.
  5. Not carrying any type of weapons or explosives into thefacility.
  6. Keeping all scheduled appointments and arriving ontime.
  7. Notifying the clinic no later than 24 hours (or as soon as possible within 24 hours) prior to the time of an appointment that he/she cannot keep the appointment asscheduled.
  8. Participating in and following the treatment plan recommended by his or her healthcare providers, to the extent he or she is able, and working with providers to achieve desired healthoutcomes.
  9. Asking questions if he or she does not understand the explanation of (or information regarding) his or her diagnosis, treatment, prognosis, and /or planned course oftreatment, alternatives or associated risks/benefits, or any other information provided to him or her regardingservices.
  10. Providing an explanation to his or her health care providers if refusing to (or unable to) participate in treatment, to the extent he or she is able, and clearly communicating wantsand needs.
  11. Informing his or her health care providers of any changes or reactions to medication or treatment.
  12. As applicable, make a good faith effort to meet financial obligations, including promptly paying for servicesprovided.
  13. Advising the clinic of any concerns, problems or dissatisfaction with the services provided or the manner in which (or by whom) they arefurnished.
  14. Utilizing all services, including grievance and complaint procedures, in a responsible,non- abusive manner, consistent with the rules and procedures of theclinic.

This grievance procedure is established to resolve complaints about your participation in the clinic. Should you feel your rights have been violated, or if you have a complaint about a decision made by clinic staff, please follow the steps below to have your complaint resolved. There will be no retaliation or barriers to services for following these procedures. Examples of complaints would be: difficulty with a health provider; discrepancy in your bill; discriminatory actions. Note that some complaints may need to be directed to your health plan or insurance companyFront office staff canassist you in where to direct your complaint.

To begin the procedure, you must schedule an appointment with the Office Manager. The Office Manager will meet with you within three (3) business days of your request. At the meeting, be prepared to present your situation clearly. Bring any documentation you have to the meeting. After discussing your problem with you and staff member(s) involved, a decision will be made. You will be given a decision within three (3) business days of the meeting.

If you are not satisfied with the decision, you may address your complaint in writing to the Administrator listed below within 10 business days. The Administrator will investigate your complaint and respond to you in writing within five (5) business days of receiving your written request.

BHS Health Center Network

Michael Ballue,Administrator
15519 Crenshaw Blvd.
Gardena, CA 90249

If you are still not satisfied, you may request a meeting to review your complaint by writing within 10 business days to:

Debbie Levan, Chief Compliance Officer
Behavioral Health Services, Inc.
15519 Crenshaw Boulevard
Gardena, CA 90249

The Chief Compliance Officer will review the investigation report and telephone or meet with you within five (5) business days of receiving your request. You will be sent a written response within five (5) business days after the phone conversation or meeting.

If you are still not satisfied, you may request a meeting to review your complaint by writing within 10 business days to:

Shirley Summers, Chief Executive Officer. (Same address as Chief Compliance Officer)A meeting will be scheduled within 30 days of receiving your request. The CEO will issue a decision within 10 business days of the meeting.

If you are not satisfied with this response, you may appeal to the agency providing payment for your services and/or to:

California Dept. of Public Health
Health Facilities Inspection
12440 E. Imperial Highway, Room 522
Norwalk, CA 90650
(800) 228-1019; (323) 869-8500 (L.A.)
(213) 974-1234 (24-Hr Emergency Line)
California Department of Public Health
Licensing and Certification
P.O. Box 997377,
MS 3000 Sacramento, California 95899-7377
(916) 552-8700 or Toll Free (800) 236-9747


This notice describes how medical information about you may be used and disclosed and how you can get access to this information. PLEASE REVIEW IT CAREFULLY.

  1. Behavioral Health Services PrivacyObligations

This notice describes the privacy practices of Behavioral Health Services, Inc. (BHS) and our employees. The notice applies to all of the medical records generated by any BHS facility. BHS uses an electronic health record (EHR) to store and retrieve much of your health information. The use of an EHR makes it easier for BHS staff to exchange and share information among our facilities.

BHS is required by federal (45 Code of Federal Regulations Parts 160 through 164) and state law to maintain the privacy of protected health information and to provide you with this notice of our legal duties and privacy practices. When we use or disclose health information, we are required to abide by the terms of this notice or other notice in effect at the time of the use or disclosure. In the event of a reportable breach of your protected health information, we are required to notify you of the improper use or disclosure of the information.

  1. Uses and Disclosures with yourConsent
    Before we provide services, except in an emergency or other special circumstance, we ask you to read and sign a written consent which authorizes us to use and disclose your protected health information to 1) provide treatment; 2) to obtain payment for services; and 3) to support health care operations such as quality improvement and customer services. Examples of how we use your information include, but are not limited to the following:
  • Treatment: Exchange of information between the treatment team for purposes of case review, treatment planning and service delivery; exchange of information between BHS facilities to facilitate transfer to other levels of care; contacting you by phone or mail to remind you of appointments, ask about missed appointments, to communicate with you about alumni activities and to follow-up on your progress during and aftertreatment.
  • Payment: Providing limited information (i.e., record number, admission date, discharge date and number of sessions attended) to the payer or funding source to obtain payment for services we have provided to you,or to an insurance company or health plan to determine whether services we plan to provide to you are covered.
  • Healthcare Operations: Review of treatment files and patient outcomes by BHS staff to ensure you are receiving quality care; review by management staff for purposes of staff supervision and training and to evaluate the need for new services; review by external auditors for purpose of audit.
  1. Uses and Disclosures without your Consent orAuthorization
  • Emergency situations: BHS may use or disclose your health information without your consent or authorization in a nemergency involving serious threat to health and safety.The information will be limited to information necessary for emergency personnel to provideservices.
  • Suspected Child or Elder/Dependent Adult Abuse or Neglect: We are required to disclose information about you without your consent or authorization if we have reason to suspect you are involved in a situation of abuse or neglect of a child or elder/dependent adult.We will only report incidents in which you are the victim of abuse with yourconsent.
  • Business Associates: Some of our services, such as laboratory tests (e.g. urine analysis) and transcription services, are provided through contracts with business associates. We may disclose some protected health information to ourbusiness associates as part of the treatment process. Other business associates include service consultants who provide building maintenance or services on our computers that house your electronic health information. Our business associates have agreed to protect the confidentiality of protected health information and not to redisclose this information without your written authorization.
  • Fundraising: We may add you to our mailing lists or other social media communications for fundraising. You may request to opt out for individual fundraising communications or all fundraising communications by sending a signed request to your counselor or the program director at your facility.
  • Court order: We may disclose your health information in the course of a judicial or administrative proceeding if we receive a legal order signed by ajudge.
  1. Uses and Disclosures with your WrittenAuthorization

Other disclosures of your protected health information will only be made with your written authorization. You have the right to refuse authorization. You also have the right to revoke such authorization in the future.

  1. Your IndividualRights

Right to Request Restrictions. You have the right to request restrictions or limitations on certain uses and disclosures of your protected health information, including the right to restrict disclosures to an insurer if you paid for your services out of pocket. To request a restriction or limitation on the use or disclosure of your protected health information, send a written request specifying clearly what restrictions you wish placed on your protected health information. Send your request to Behavioral Health Services, Inc. 15519 Crenshaw Boulevard, Gardena, CA 90249. BHS will consider all requests for restrictions on use and disclosure of protected health information. BHS is not required to agree to your request. If we do not agree and you are an active client, your counselor will discuss your request with you. If your requested restrictions would interfere with our provision of treatment services to you, you will be given the choice to withdraw your request for restrictions on the use and disclosure of your protected health information, or to terminate your treatment with BHS and transfer to another health careprovider.

Right to Receive Confidential Communications. You have the right to receive communications from BHS in a certain way, such as by phone, U.S. mail or email, or at a certain location. To receive communications at the location of your choice, it is your responsibility to notify your counselor of the location (i.e. mailing address , telephone number, email address, etc.) where you wish to receive communications. We will consider all requests carefully, notify you of any risks, and honor reasonable requests. If you wish to change the location or method by which you receive communications from us at some time after your discharge from treatment, you may send your change in writing to: Behavioral Health Services, Inc. 15519 Crenshaw Blvd, Gardena, CA 90249.

Right to Inspect and Copy your Health Information. You have the right to inspect and/or receive a hard copy or electronic copy of protected health information in your client record. To inspect or request a copy of your record, you must make your request in writing to the location where you are receiving services. There is a fee charged for inspecting or making a copy of your record.

You may receive limited information (face sheet and discharge summary) for no cost.

Right to Amend Your Records. If you believe your protected health information is inaccurate and needs amendment, you may request that your record be amended. To make a request to amend your protected health information, you must notify BHS in writing specifying the information to be amended and the reason for the amendment. BHS will review your request for amendment. No later than 60 days after receipt of your request, BHS will either (1) amend your protected health information and notify you that the amendment you requested has been made, or (2) notify you that your request is denied and the reason for the denial. If your request is denied, you may submit a written statement disagreeing with the denial which will be placed in yourrecord.

Right to Receive Accounting of Disclosures. You have a right to receive an accounting of disclosures of your protected health information made by BHS. We maintain a list of disclosures made with your authorization or made to business associates in the provision of your treatment services. The accounting includes: the date information was disclosed, the entity or person who received the information, a brief description of protected health information disclosed, and the purpose of the disclosure. To receive an accounting of disclosures of your protected health information you must send a written request to Behavioral Health Services, Inc. 15519 Crenshaw Boulevard, Gardena, CA 90249. Your requestmust include the time period you wish an accounting for, your full name and date of birth to assist us in locating your file. The accounting will be provided to you within 60 days of receipt of your written request.

For More Information or to File a Complaint: If you want further information about your privacy rights, or are concerned that we have violated your rights or disagree with a decision we have made about your health information, you may contact the BHS Privacy Officer at (310) 679-9126. You may also file a written complaint with the Secretary of Health and Human Services (HHS). Upon request, the BHS Privacy Officer will provide you with the correct address for the HHS Secretary. You must name the entity that is the subject of the complaint and describe the acts or omission believed to be in violation of the applicable requirements of 45 CFR part 160 or the applicable standards, requirements, and implementation specifications of 45 CFR subpart E of part 164. We will not retaliate against you if you file a complaint with the HHS Secretary or with us.

Right to Receive a Copy of this Notice. You also have a right to receive a copy of this notice.

BHS reserves the right to revise our practices at anytime. At the time we change our practices regarding the use of protected health information, we will revise this notice. The revised notice will be posted and available in all BHS treatment locations. Clients may also request a copy of the current privacy notice by asking a staff member at the location where they are receiving services or by sending a written request to: Behavioral Health Services, Inc. 15519 Crenshaw Boulevard, Gardena, CA90249.

This notice is effective September 1, 2013 and remains in effect until a notice of amendment is published.