BHRS Authorization and Consent Forms
- Client Access to Chart (PHI): EnglishSpanishTagalog
- Client Request to Amend Medical Record (PHI)
- Client Request to Restrict Use or Disclosure of Protected Health Information (PHI)
- Chapter 26.5 Assessment: EnglishSpanish
- Exchange, Disclose, Information & Release Medical Records-Use or Disclosure of Protected Health Information: EnglishSpanishTagalogTongan
- Media Release Form (SMC Employee, Contractor, Client or Volunteer)
- Medication Consent:
- Senior Peer Counselor:
- Session Recording and/or 1-Way Mirror Observation: EnglishSpanish
- Staff Request to Block BHRS Electronic Medical Record
- Student Observation at Behavioral Health Clinic
- Treatment Consent with Receipt Notice of Privacy Practices: Tongan
- Urine Toxicology Screening Agreement
- Verbal Release of Protected Health Information to Family, Friends, or Individuals Providing Social Support: EnglishSpanishTagalog
- Verbal Release of Protected Health Information to San Mateo County Law Enforcement
- Youth Emergency/Medication Consent Release Form