Consent for Services – MH 500
- English
- Arabic
- Armenian
- Chinese (Simplified)
- Chinese (Traditional)
- Farsi
- Khmer
- Korean
- Russian
- Spanish
- Tagalog
- Vietnamese
Consent for Observation – MH 701
Medication Consent – MH 730
Consent for TMS – MH 733
Medication Treatment Authorization Request Form (TAR) – MH 417
Health Information Exchange (HIE) – Change of Sharing Status – MH 728
Outpatient Medication Review
Outpatient Medication Review – MH 556 (Effective 9/26/16)
Outpatient Medication Review (Spanish) – MH 556S (Effective 9/26/16)
Outpatient Medication Review (Mandarin) – MH 556M (Effective 9/26/16)
Outpatient Medication Review (Cantonese) – MH 556C (Effective 9/26/16)
Outpatient Medication Review (Other Chinese) – MH 556OC (Effective 9/26/16)
Outpatient Medication Review (Korean) – MH 556K (Effective 9/26/16)
Outpatient Medication Review (Vietnamese) – MH 556V (Effective 9/26/16)
Outpatient Medication Review (Tagalog) – MH 556T (Effective 9/26/16)
Outpatient Medication Review (Khmer) – MH 556KM
Outpatient Medication Review (Arabic) – MH 556A (Effective 9/26/16)
Outpatient Medication Review (Armenian) – MH 556AR (Effective 9/26/16)
Outpatient Medication Review (Farsi) – MH 556F (Effective 9/26/16)
Outpatient Medication Review (Russian) – MH 556R (Effective 9/26/16)
Caregivers Authorization Affidavit
Caregivers Authorization Affidavit – MH 646
Caregivers Authorization Affidavit (Spanish) – MH 646S
Caregivers Authorization Affidavit (Korean) – MH 646K
Caregivers Authorization Affidavit (Khmer) – MH 646KM
Caregivers Authorization Affidavit (Tagalog) – MH 646T
Caregivers Authorization Affidavit (Russian) – MH 646R
Authorization for Use or Disclosure of Protected Health Information
Authorization for Use or Disclosure of Protected Health Information – MH 602
Authorization for Use or Disclosure of Protected Health Information Arabic – MH 602A
Authorization for Use or Disclosure of Protected Health Information Armenian – MH 602AR
Authorization for Use or Disclosure of Protected Health Information Cantonese – MH 602CAN
Authorization for Use or Disclosure of Protected Health Information Farsi- MH 602F
Authorization for Use or Disclosure of Protected Health Information Khmer- MH 602CAM
Authorization for Use or Disclosure of Protected Health Information Korean – MH 602K
Authorization for Use or Disclosure of Protected Health Information Mandarin – MH 602M
Authorization for Use or Disclosure of Protected Health Information Other Chinese – MH 602OC
Authorization for Use or Disclosure of Protected Health Information Russian – MH 602R
Authorization for Use or Disclosure of Protected Health Information Spanish – MH 602S
Authorization for Use or Disclosure of Protected Health Information Tagalog – MH 602T
Authorization for Use or Disclosure of Protected Health Information Vietnamese – MH 602V
Acknowledgement of Receipt
Acknowledgment of Receipt (English) – MH 601E
Acknowledgment of Receipt (Spanish) – MH 601S
Los Angeles County Health Agency Notice of Privacy Practices (English)
Los Angeles County Health Agency Notice of Privacy Practices (Spanish)