Consent/Authorization

Consent for E-mail – MH 708

Consent for Observation – MH 701

Consent of Minor – MH521E

Medication Consent and Treatment Plan – MH 730

Consent for Text Messaging/Video Chat – MH 732

Consent for TMS – MH 733

Medication Treatment Authorization Request Form (TAR) – MH 417

Health Information Exchange (HIE) – Change of Sharing Status – MH 728

Consent for Services

Consent for Services – MH 500E
Consent for Services (Spanish) – MH 500S
Consent for Services (Korean) – MH 500K
Consent for Services (Russian) – MH 500R
Consent for Services (Tagalog) – MH 500T

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)

Consent to Photograph/Audio Record

Consent to Photograph/Audio Record – MH 528
Consent to Photograph/Audio Record (Spanish) – MH 528S
Consent to Photograph/Audio Record (Korean) – MH 528K
Consent to Photograph/Audio Record (Khmer) – MH 528KM
Consent to Photograph/Audio Record (Tagalog) – MH 528T
Consent to Photograph/Audio Record (Russian) – MH 528R

Consent for Tele-Psychiatric Services

Consent for Tele-Psychiatric Services – MH 652
Consent for Tele-Psychiatric Services (Spanish) – MH 652S
Consent for Tele-Psychiatric Services (Korean) – MH 652K
Consent for Tele-Psychiatric Services (Khmer) – MH 652KM
Consent for Tele-Psychiatric Services (Tagalog) – MH 652T
Consent for Tele-Psychiatric Services (Russian) – MH 652R

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

Advance Health Care Directive Acknowledgment

Advance Health Care Directive – MH 635
Advance Health Care Directive (Spanish) – MH 635S
Advance Health Care Directive (Korean) – MH 635K
Advance Health Care Directive (Khmer) – MH 635KM
Advance Health Care Directive (Tagalog) – MH 635T
Advance Health Care Directive (Russian) – MH 635R

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)