Consent/Authorization
Consent for Services
Consent for Services – MH 500 (Effective 7/1/24)
Consent for Services (Arabic) – MH 500A (Effective 7/1/24)
Consent for Services (Armenian) – MH 500AR (Effective 7/1/24)
Consent for Services (Farsi) – MH 500F (Effective 7/1/24)
Consent for Services (Khmer) – MH 500KH (Effective 7/1/24)
Consent for Services (Korean) – MH 500KO (Effective 7/1/24)
Consent for Services (Russian) – MH 500R (Effective 7/1/24)
Consent for Services (Simplified Chinese) – MH 500SC (Effective 7/1/24)
Consent for Services (Spanish) – MH 500S (Effective 7/1/24)
Consent for Services (Tagalog) – MH 500T (Effective 7/1/24)
Consent for Services (Traditional Chinese) – MH 500TC (Effective 7/1/24)
Consent for Services (Vietnamese) – MH 500V (Effective 7/1/24)
Consent For INFRA Low Feedback (ILF) Neurofeedback Treatment
Consent For INFRA Low Feedback (ILF) Neurofeedback Treatment – MH 762 (Effective 10/25/25)
Consent For INFRA Low Feedback (ILF) Neurofeedback Treatment (Arabic) – MH 762A (Effective 10/25/25)
Consent For INFRA Low Feedback (ILF) Neurofeedback Treatment (Armenian) – MH 762AR (Effective 10/25/25)
Consent For INFRA Low Feedback (ILF) Neurofeedback Treatment (Farsi) – MH 762F (Effective 10/25/25)
Consent For INFRA Low Feedback (ILF) Neurofeedback Treatment (Khmer) – MH 762KH (Effective 10/25/25)
Consent For INFRA Low Feedback (ILF) Neurofeedback Treatment (Korean) – MH 762KO (Effective 10/25/25)
Consent For INFRA Low Feedback (ILF) Neurofeedback Treatment (Russian) – MH 762R (Effective 10/25/25)
Consent For INFRA Low Feedback (ILF) Neurofeedback Treatment (Simplified Chinese) – MH 762SC (Effective 10/25/25)
Consent For INFRA Low Feedback (ILF) Neurofeedback Treatment (Spanish) – MH 762S (Effective 10/25/25)
Consent For INFRA Low Feedback (ILF) Neurofeedback Treatment (Tagalog) – MH 762T (Effective 10/25/25)
Consent For INFRA Low Feedback (ILF) Neurofeedback Treatment (Traditional Chinese) – MH 762TC (Effective 10/25/25)
Consent For INFRA Low Feedback (ILF) Neurofeedback Treatment (Vietnamese) – MH 762V (Effective 10/25/25)
Consent For Transcranial Magnetic Stimulation (TMS) Treatment
Consent For Transcranial Magnetic Stimulation (TMS) Treatment – MH 733 (Effective 8/1/26)
Consent For Transcranial Magnetic Stimulation (TMS) Treatment (Arabic) – MH 733A (Effective 8/1/26)
Consent For Transcranial Magnetic Stimulation (TMS) Treatment (Armenian) – MH 733AR (Effective 8/1/26)
Consent For Transcranial Magnetic Stimulation (TMS) Treatment (Farsi) – MH 733F (Effective 8/1/26)
Consent For Transcranial Magnetic Stimulation (TMS) Treatment (Khmer) – MH 733KH (Effective 8/1/26)
Consent For Transcranial Magnetic Stimulation (TMS) Treatment (Korean) – MH 733KO (Effective 8/1/26)
Consent For Transcranial Magnetic Stimulation (TMS) Treatment (Russian) – MH 733R (Effective 8/1/26)
Consent For Transcranial Magnetic Stimulation (TMS) Treatment (Simplified Chinese) – MH 733SC (Effective 8/1/26)
Consent For Transcranial Magnetic Stimulation (TMS) Treatment (Spanish) – MH 733S (Effective 8/1/26)
Consent For Transcranial Magnetic Stimulation (TMS) Treatment (Tagalog) – MH 733T (Effective 8/1/26)
Consent For Transcranial Magnetic Stimulation (TMS) Treatment (Traditional Chinese) – MH 733TC (Effective 8/1/26)
Consent For Transcranial Magnetic Stimulation (TMS) Treatment (Vietnamese) – MH 733V (Effective 8/1/26)
Consent for TMS
Consent for TMS – MH 733
Medication Consent
Medication Consent – MH 730 (Effective 8/1/26)
Medication Consent (Arabic) – MH 730A (Effective 8/1/26)
Medication Consent (Armenian) – MH 730AR (Effective 8/1/26)
Medication Consent (Farsi) – MH 730F (Effective 8/1/26)
Medication Consent (Khmer) – MH 730KH (Effective 8/1/26)
Medication Consent (Korean) – MH 730KO (Effective 8/1/26)
Medication Consent (Simplified Chinese) – MH 730SC (Effective 8/1/26)
Medication Consent (Spanish) – MH 730S (Effective 8/1/26)
Medication Consent (Tagalog) – MH 730T (Effective 8/1/26)
Medication Consent (Traditional Chinese) – MH 730TC (Effective 8/1/26)
Medication Consent (Vietnamese) – MH 730V (Effective 8/1/26)
Health Information Exchange (HIE) – Change of Sharing Status
Health Information Exchange (HIE) – Change of Sharing Status – MH 728
Health Information Exchange (HIE) – Change of Sharing Status – MH 728 (Effective 8/1/26)
Health Information Exchange (HIE) – Change of Sharing Status (Arabic) – MH 728A (Effective 8/1/26)
Health Information Exchange (HIE) – Change of Sharing Status (Armenian) – MH 728AR (Effective 8/1/26)
Health Information Exchange (HIE) – Change of Sharing Status (Farsi) – MH 728F (Effective 8/1/26)
Health Information Exchange (HIE) – Change of Sharing Status (Khmer) – MH 728KH (Effective 8/1/26)
Health Information Exchange (HIE) – Change of Sharing Status (Korean) – MH 728KO (Effective 8/1/26)
Health Information Exchange (HIE) – Change of Sharing Status (Simplified Chinese) – MH 728SC (Effective 8/1/26)
Health Information Exchange (HIE) – Change of Sharing Status (Spanish) – MH 728S (Effective 8/1/26)
Health Information Exchange (HIE) – Change of Sharing Status (Tagalog) – MH 728T (Effective 8/1/26)
Health Information Exchange (HIE) – Change of Sharing Status (Traditional Chinese) – MH 728TC (Effective 8/1/26)
Health Information Exchange (HIE) – Change of Sharing Status (Vietnamese) – MH 728V (Effective 8/1/26)
Consent for Staff, Volunteer, Intern Observation
Consent for Staff, Volunteer, Intern Observation – MH 701 (Effective 8/1/26)
Consent for Staff, Volunteer, Intern Observation (Arabic) – MH 701A (Effective 8/1/26)
Consent for Staff, Volunteer, Intern Observation (Armenian) – MH 701AR (Effective 8/1/26)
Consent for Staff, Volunteer, Intern Observation (Farsi) – MH 701F (Effective 8/1/26)
Consent for Staff, Volunteer, Intern Observation (Khmer) – MH 701KH (Effective 8/1/26)
Consent for Staff, Volunteer, Intern Observation (Korean) – MH 701KO (Effective 8/1/26)
Consent for Staff, Volunteer, Intern Observation (Russian) – MH 701R (Effective 8/1/26)
Consent for Staff, Volunteer, Intern Observation (Simplified Chinese) – MH 701SC (Effective 8/1/26)
Consent for Staff, Volunteer, Intern Observation (Spanish) – MH 701S (Effective 8/1/26)
Consent for Staff, Volunteer, Intern Observation (Tagalog) – MH 701T (Effective 8/1/26)
Consent for Staff, Volunteer, Intern Observation (Traditional Chinese) – MH 701TC (Effective 8/1/26)
Consent for Staff, Volunteer, Intern Observation (Vietnamese) – MH 701V (Effective 8/1/26)
Caregiver’s Authorization Affidavit
Caregiver’s Authorization Affidavit – MH 646 (Effective 1/2/26)
Caregiver’s Authorization Affidavit (Arabic) – MH 646A (Effective 1/2/26)
Caregiver’s Authorization Affidavit (Armenian) – MH 646AR (Effective 1/2/26)
Caregiver’s Authorization Affidavit (Farsi) – MH 646F (Effective 1/2/26)
Caregiver’s Authorization Affidavit (Khmer) – MH 646KH (Effective 1/2/26)
Caregiver’s Authorization Affidavit (Korean) – MH 646KO (Effective 1/2/26)
Caregiver’s Authorization Affidavit (Russian) – MH 646R (Effective 1/2/26)
Caregiver’s Authorization Affidavit (Simplified Chinese) – MH 646SC (Effective 1/2/26)
Caregiver’s Authorization Affidavit (Spanish) – MH 646S (Effective 1/2/26)
Caregiver’s Authorization Affidavit (Tagalog) – MH 646T (Effective 1/2/26)
Caregiver’s Authorization Affidavit (Traditional Chinese) – MH 646TC (Effective 1/2/26)
Caregiver’s Authorization Affidavit (Vietnamese) – MH 646V (Effective 1/2/26)
Client’s Request for Access/Inspection to Health Information
Client’s Request for Access/Inspection to Health Information – MH 603
Clients Request For Access Inspection To Health Information (Vietnamese) – MH 603VIE
Clients Request For Access Inspection To Health Information (Korean) – MH 603KOR
Clients Request For Access Inspection To Health Information (Armenian) – MH 603ARM
MH 603 (Traditional Chinese) – MH 603TC
MH 603 (Russian) – MH 603R
Clients Request For Access Inspection To Health Information (Tagalog) – MH 603TAG
Clients Request For Access Inspection To Health Information (Arabic) – MH 603ARA
Clients Request For Access Inspection To Health Information (Khmer) – MH 603KMH
MH 603 (Farsi) – MH 603F
MH 603 (Simplified Chinese) – MH 603SC
MH 603 (Spanish) – MH 603S
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 Chinese Simplified – MH 602SC
Authorization for Use or Disclosure of Protected Health Information Chinese Traditional – MH 602TC
Authorization for Use or Disclosure of Protected Health Information Farsi – MH 602F
Authorization for Use or Disclosure of Protected Health Information Khmer – MH 602KH
Authorization for Use or Disclosure of Protected Health Information Korean – MH 602KO
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 (Effective 8/1/26)
Acknowledgment of Receipt (Spanish) – MH 601S (Effective 8/1/26)
Los Angeles County Health Agency Notice of Privacy Practices (English)
Los Angeles County Health Agency Notice of Privacy Practices (Spanish)
Health Information Management Forms
Letter Response to Client Request to Health Information – MH 604
Client’s Request for Review of Denial of Access – MH 605
Final Letter to Client for Review of Denial – MH 606
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 (Effective 2/11/11)
Consent to Photograph/Audio Record (Khmer) – MH 528KH (Effective 2/11/11)
Consent to Photograph/Audio Record (Korean) – MH 528KO (Effective 2/11/11)
Consent to Photograph/Audio Record (Russian) – MH 528SR (Effective 2/11/11)
Consent to Photograph/Audio Record (Spanish) – MH 528S (Effective 4/3/13)
Consent to Photograph/Audio Record (Tagalog) – MH 528T (Effective 2/11/11)