FORMS

Clinical Forms for Reviewing over the Internet.

While our HIPAA Policy has always been available online, we added the additional forms on this website during the 2020 Stay at Home Order so that individuals receiving services over telehealth or telephone could have access to viewing these forms.

 

HIPAA Policy

Portia Bell Hume Behavioral Health and Training Center (The Hume Center) is committed to maintaining the privacy of your protected mental health information, which includes information about your mental health condition and the care and treatment you receive from The Hume Center. The creation of a record detailing the care and services you receive helps our office to provide you with quality health care and is also required by law. Our HIPAA Policy details how your "Protected Health Information" (PHI) may be used and disclosed to third parties and also details your rights regarding your PHI.

Please click this link to view, print, or save this documentt. HIPAA PRIVACY NOTICE.pdf

 

Alameda County Informing Materials

For clients receiving services in Alameda County. Alameda County Mental Health Plan has provided this this packet of informingmaterials that explains your rights and responsibilities.

Please click this link to view, print, or save this documentt. INFORMING MATERIALS -- ALAMEDA COUNTY

 

Informed Consent

This document contains all the important information you need to know as you begins services and about your provider's status.

Please click this link to view, print, or save this documentt. INFORMED CONSENT.PDF

 

Telehealth Informed Consent

This document contains all of the additiuonal information you need to know before starting services over telehealth.

Please click this link to view, print, or save this documentt. TELEHEALTH INFORMED CONSENT.PDF 

 

Release of Information Authorization

This document is what is used for a client to allow their provider to exchange information to or from someone else or a program.

Please click this link to view, print, or save this documentt. RELEASE OF INFORMATION.PDF

 

Patient's Rights

This document outlines the rights we believe our clients deserve and that we aspire to uphold at all times.

Please click this link to view, print, or save this documentt. PATIENT'S RIGHTS.PDF

 

Description of Services

This document includes important information about our programs. Call one of our clinics for the most up to date information.

Please click this link to view, print, or save this documentt. DESCRIPTION OF SERVICES.PDF

 

Grievance Policy and Grievance Form

Our grievance policy outslines the steps to take if you feel you have a grievance about a Hume Center staff member or service. Please click this link to view, print, or save this documentt. GRIEVANCE POLICY.PDF

This grievance request form should be filled out and submitted to a Hume Center clinic in order to file your grievance. Please click this link to view, print, or save this documentt. GRIEVANCE REQUEST.PDF