Form DHCS5080 "C-9 - Personal Rights - Substance Use Disorder Treatment Facilities" - California

What Is Form DHCS5080?

This is a legal form that was released by the California Department of Health Care Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2016;
  • The latest edition provided by the California Department of Health Care Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DHCS5080 by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.

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Download Form DHCS5080 "C-9 - Personal Rights - Substance Use Disorder Treatment Facilities" - California

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State of California — Health and Human Services Agency
Department of Health Care Services
Licensing and Certification Branch, MS 2600
PO Box 997413
Sacramento, CA 95899-7413
C-9 – PERSONAL RIGHTS – SUBSTANCE USE DISORDER TREATMENT FACILITIES
In accordance with Title 9, Chapter 5, Section 10569, of the California Code of Regulations, each person
receiving services from a residential alcoholism or drug abuse recovery or treatment facility shall have
rights which include, but are not limited to, the following:
 The right to confidentiality as provided for in Title 42, Section 2.1 through 2.67-1, Code of
Federal Regulations.
 To be accorded dignity in personal relationships with staff and other individuals.
 To be accorded safe, healthful, and comfortable accommodations to meet his or her needs.
 To be free from intellectual, emotional and/or physical abuse.
 To be informed by the licensee of the provisions of law regarding complaints including, but
not limited to, the address and telephone number of the Department of Health Care Services.
 To be free to attend religious services or activities of his or her choice and to have visits from
a spiritual advisor provided that these services or activities do not conflict with facility
program requirements. Participation in religious services will be voluntary only.
COMPLAINTS
In accordance with Title 9, Chapter 5, Section 10543(a), of the California Code of Regulations, any
individual may request an inspection of an alcoholism or drug abuse recovery or treatment facility.
Complaints should be directed to:
Department of Health Care Services
Licensing and Certification Branch, MS 2600
PO Box 997413
Sacramento, CA 95899-7413
Attention: Complaint Coordinator
(916) 324-4505
FAX (916) 322-2658
TDD: (916) 445-1942
Acknowledgement
I have been personally advised and have received a copy of my personal rights and have been informed of
the provisions for complaints at the time of my admission to:
(Name of Facility)
(Residents Signature)
DHCS 5080 (11/2016)
State of California — Health and Human Services Agency
Department of Health Care Services
Licensing and Certification Branch, MS 2600
PO Box 997413
Sacramento, CA 95899-7413
C-9 – PERSONAL RIGHTS – SUBSTANCE USE DISORDER TREATMENT FACILITIES
In accordance with Title 9, Chapter 5, Section 10569, of the California Code of Regulations, each person
receiving services from a residential alcoholism or drug abuse recovery or treatment facility shall have
rights which include, but are not limited to, the following:
 The right to confidentiality as provided for in Title 42, Section 2.1 through 2.67-1, Code of
Federal Regulations.
 To be accorded dignity in personal relationships with staff and other individuals.
 To be accorded safe, healthful, and comfortable accommodations to meet his or her needs.
 To be free from intellectual, emotional and/or physical abuse.
 To be informed by the licensee of the provisions of law regarding complaints including, but
not limited to, the address and telephone number of the Department of Health Care Services.
 To be free to attend religious services or activities of his or her choice and to have visits from
a spiritual advisor provided that these services or activities do not conflict with facility
program requirements. Participation in religious services will be voluntary only.
COMPLAINTS
In accordance with Title 9, Chapter 5, Section 10543(a), of the California Code of Regulations, any
individual may request an inspection of an alcoholism or drug abuse recovery or treatment facility.
Complaints should be directed to:
Department of Health Care Services
Licensing and Certification Branch, MS 2600
PO Box 997413
Sacramento, CA 95899-7413
Attention: Complaint Coordinator
(916) 324-4505
FAX (916) 322-2658
TDD: (916) 445-1942
Acknowledgement
I have been personally advised and have received a copy of my personal rights and have been informed of
the provisions for complaints at the time of my admission to:
(Name of Facility)
(Residents Signature)
DHCS 5080 (11/2016)