BHRS Authorization and Consent Forms
AVATAR CONSENT FORMS
Clinical Consent Form – Avatar
Medication Consent Form - Avatar
- Medication form scripts for clinicians Chinese Medication Script Spanish Medication Script Russian Medication Script Tagalog Medication Script Tongan Medication Script
Release of Information (ROI)
- ROI Exchange, Disclose, Information & Release Medical Records-Use or Disclosure of Protected Health Information
- Client Access to Chart (PHI)
- Client Request to Amend Medical Record (PHI)
- Client Request to Restrict Use or Disclosure of Protected Health Information (PHI)
- Media Release Form (SMC Employee, Contractor, Client or Volunteer)
- Staff Request to Block BHRS Electronic Medical Record
Medication
Treatment Related
- Cell Phone Agreement
- Treatment Consent with Receipt Notice of Privacy Practices
- Telehealth Informed Consent
- Notice of License
Clinical
- Change of Provider Request
- Senior Peer Counselor:
- Session Recording and 1-Way Mirror Observation: English Spanish
- Student Observation at Behavioral Health Clinic
- Urine Toxicology Screening Agreement
- Youth Emergency/Medication Consent Release Form