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 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 (Kmer) – 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 (Kmer) – 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 (Kmer) – 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 (Kmer) – MH 646KM

Caregivers Authorization Affidavit (Tagalog) – MH 646T

Caregivers Authorization Affidavit (Russian) – MH 646R

 

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)

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