Presumptive Transfer: County Forms

	A	B	C	D	E
1	County	Form name and link	Language	File name	Comments

2	Alameda	The Presumptive Transfer Point of Contact can provide information on the forms used in this county
3	Alpine	Authorization For The Use And Disclosure Of Health Information	English	Alpine County Blank printable version
4	Alpine	Alpine County Behavioral Health Services Informed Consent	English	Alpine County BHS Informed Consent
5	Alpine	Protective Services Authorization For Release Of Information	English	Alpine County CPS_APS ROI
6	Amador	Authorization for Release of Patient Information	English	Amador Authorization for Use and Disclosure of PHI
7	Amador	Consent for Services/Authorization for the Release of Confidential Substance Abuse and Mental Health Information	English	Amador BH Consent-Release for Services
8	Butte	Authorization for Use or Disclosure of Health Information	English	Need to Fill In - Release of Information
9	Butte	BCDBH Informed Consent (MH) - English	English	Informed Consent
10	Calaveras	Agreement for Services	English	HHS YOUTH AGREEMENT FOR SERVICES MH (rev 091614)
11	Calaveras	Authorization for the Use and Disclosure of Health Information	English	Reciprocal Release
12	Colusa	Informed Consent For Services	English	Informed Consent with NS agreement
13	Colusa	Informed Consent For Services	English/Spanish	Informed Consent (english and spanish)
14	Colusa	Authorization to Use and Disclose Protected Health Information (PHI)	English	Release of Inf-CCBH
15	Colusa	Authorization to Use and Disclose Protected Health Information/Autorization para Uso y la Revelacion para proteger de Infomacion la Salud	English/Spanish	Release of Inf CCBH
16	Contra Costa	Authorization for Contra Costa Health Services Mental Health Division to Receive Medical and Mental Health Information	English	Contra Costa County MHP Auth to release & recieve forms
17	Contra Costa	Patients' Rights	English	ContraCostaCounty_Consents
18	Del Norte	Consent for Outpatient Mental Health Treatment	English	DNCMH Consent to Treat
19	Del Norte	Authorization for Release of Confidential Client Information	English	RELEASE OF INFORMATION - Behavioral Health Branch
20	El Dorado	Authorization to Use/Disclose Protected Health Information	English	ROI Authorization WS OP to Exchange PHI updated Jan. 2014 - fillable +minor
21	El Dorado	Consent for Services	English	Consent for Services
22	Fresno	Consent for Treatment	English	Fresno Consent for Treatment
23	Fresno	Notice of Presumptive Transfer of Specialty Mental Health Services for Foster Child or Youth Placed Out of County	English	Notice_of_Transfer_of_Responsibility_for_SMHS (002)
24	Glenn	Informed Consent for Services	English	Informed Consent for Services (English) FINAL 09-19-18
25	Glenn	Consentimiento Informado para Servicios	Spanish	Informed Consent for Services (Spanish) FINAL 04-4-13
26	Glenn	Authorization for Release of Confidential Information and/or Records to the Multidisciplinary Services Team	English	Release of Information Children's Services MDT Form 11-01-18
27	Glenn	Universal Release of Information (URI)	English	URI 5 1 15 English
28	Glenn	Liberación Universal de Información (URI)	Spanish	URI 5 1 15 Spanish
29	Humboldt	1006 – Authorization For Disclosure Of Information	English	1006 ROI
30	Humboldt	1009 Consent For Evaluation And/Or Treatment Of A Minor	English/Spanish	Consent for Eval _ Treatment of Minor
31	Imperial	Autorización para Uso o Divulgación de Información	Spanish	0665_001
32	Imperial	Authorization for the Use or Disclosure of Information	English	0666_001
33	Imperial	Authorization for Evaluation and/or Treatment of a Minor	English	0667_001
34	Imperial	Autorización para Evaluación y/o Tratamiento de un Menor de Edad	Spanish	0668_001
35	Inyo	Consent To Treat - Advise Of Free Choice & Confidentiality	English	Inyo County - Consent to Treat
36	Inyo	Authorization For Release Of Confidential Health Information	English	Inyo County - Release of Information
37	Kern	Consent For Treatment	English	Kern BHRS Consent to Treat
38	Kern	Order Authorizing Mental Health Assessment, Treatment, Services Release & Exchange of Information	English	final sample MHO.10.20.17
39	Kern	Decision Tree for Consent to Treat/Authorization to Release Information	English	MH Consent Chart_2final version2.17.17
40	Kings	Content for Treatment Services	English	Recent Intake CPS packet1
41	Lassen	Consent for the Release of Confidential Information	English	ROI
42	Los Angeles	Non-minor Dependent 2-Way Authorization For Sharing Information	English	Consent 2-Way for NMD DCFS 6010
43	Los Angeles	Parental Consent For Child’s Mental Health/Regional Center Developmental Assessment And Participation In Mental Health Services	English	DCFS 179-MH Final[1]
44	Los Angeles	Consentimiento De Los Padres Para Otorgarle Al Menor Una Evaluacion De Salud Mental/Desarrollo	Spanish	DCFS 179 MH -Spanish
45	Los Angeles	Nonminor Dependent Informed Consent	English	DCFS 6009 NMD Consent
46	Los Angeles	Authorization For Disclosure Of Child’s Protected Health Information (Phi)	English	DCFS 179-PHI Final[1]
47	Los Angeles	Autorizacion Para La Revelacion De Informacion Protegida Sobre La Salud Del Niño(a)	Spanish	DCFS 179 PHI SPANISH
48	Los Angeles	Order For Mental Health And Developmental Assessment, Services And Release Of Information	English	Stand Alone Court Order Language
49	Madera	General: Authorization to Use & Disclose Protected Health Information	English	General ROI English 05-18-17
50	Madera	General: Authorization to Use & Disclose Protected Health Information (Electronic Template)	English	General ROI English 05-18-17 Electronic TEMPLATE
51	Madera	Autorizacion General: Para el Uso, Acceso o Intercambio de Informacion Protegida de Salud	Spanish	General ROI Spanish 05-18-17
52	Madera	Autorizacion General: Para el Uso, Acceso o Intercambio de Informacion Protegida de Salud (Plantilla Electronica)	Spanish	General ROI-Spanish 05-18-17 Electronic TEMPLATE
53	Madera	Multiple forms including Consent for Evaluation/Treatment, Notice of Transfer of Responsibility, Limits of Confidentiality, Treatment Compliance Agreement	English	Madera County
54	Marin	Referral Request for Presumptive Transfer Child in Marin County (AB1299)	English	Marin County presumptive_transfer_referral_fillin_form_2017.12.21pdf
55	Mariposa	Consent for Evaluation and/or Treatment of a Client/Minor	English	Mariposa consent to treat
56	Mariposa	Universal Authorization For The Release Of Protected Health Information (Not Including SUD) Or Other Confidential Client Information	English	Release of PHI Info
57	Mariposa	Authorization for the Release of Protected Health Information	English	Mariposa Release
58	Mendocino	Consent to Treat packet (multiple forms)	English	Mendo Consents
59	Merced	Authorization For Release Of Information/Autorizacion Para Tratamiento De Un Menor	English/Spanish	Merced County BHRS Consent Forms Packet
60	Merced	Authorization for Release of Protected Health Information	English	_Auth for Release Of Information 2.27.19 (2)
61	Modoc	Modoc County Behavioral Health Consent to Treatment/Admission Agreement	English	Modoc County Behavioral Health Consent to Treatment 2014-10-13
62	Modoc	Authorization for Release of Confidential and Protected Health Information	English	Modoc County Health Services Release of Information 2018-03-05
63	Mono	Authorization for Use or Disclosure of Health Information	English	ROI_twosided
64	Mono	Consent For Treatment	English	consent to treat
65	Monterey	Authorization for Disclosure of Confidential Health Information Within Monterey County Behavioral Health System	English	MCBH-Authorization-for-Use-Exchange-and-or-Disclosure-of-Confidential-Be...
66	Monterey	Informed Consent	English	MCBH_Informed_Consent-2018-05-30
67	Monterey	General - Authorization for Use, Exchange, and/or Disclosure of Confidential Behavioral Health Information	English	MCBH-Authorization-for-Use-Exchange-and-or-Disclosure-of-Confidential-Be...
68	Napa	Authorization To Consent To Treatment Of Minor	English	Authorization(Medical Consent)
69	Napa	Authorization For Disclosure Of Information	English	Authorization for Use or Disclosure of Health Information
70	Nevada	Consent For Outpatient Treatment	English	Consent for Services - English
71	Nevada	Consentimiento para tratamiento externo	Spanish	Consent for Services - Spanish 07-2018
72	Nevada	Authorization for Use or Disclosure of Health Information	English	Release of Information Auth
73	Orange	Informed Consent For Services	English	HCA Informed Consent 2016-English
74	Orange	Authorization To Use & Disclose Protected Health Information	English	Authorization Form - General 2017 Fillable
75	Placer	Presumptive Transfer Form	English	MCBH_Informed_Consent-2018-05-30
76	Plumas	Informed Consent and Authorization to Bill	English	Informed Consent
77	Plumas	Release of Protected Health Information Authorization	English	Release of Information
78	Riverside	Child/Adult Consent To Treat	English	combined_consent_treat_Eng_90
79	Riverside	Authorization for Use and/or Disclosure of Patient Health Information	English	universal_consent_117
80	Riverside	Consentimiento Para Tratar A Un Niño O Un Adulto	Spanish	combined_consent_treat_Span_90
81	Riverside	Autorización para el uso y/o divulgación de Información de Salud del Paciente	Spanish	universal_consent_spa_117
82	Sacramento	The Presumptive Transfer Point of Contact can provide information on the forms used in this county
83	San Benito	Authorization for Release of Information	English	0022-ROI_14ptfont_091015
84	San Benito	Consent For Mental Health Services	English	0088-Consent OutPatient Treatment_ English_090612
85	San Benito	Consentimento Para Servicios De Tratamiento Externo	Spanish	0088-Consent OutPatient Treatment_091412_ Spanish (3)
86	San Benito	Autorización Para La Liberación De Información	Spanish	0022-ROI_14ptfont_SPANISH_091015
87	San Benito	Health Questionnaire, Client Intake Checklist, Consent for Mental Health Services, Notice of Privacy Practices Acknowledgement, Release of Information/Payment Agreement	English	San Benito County BH Consent Forms
88	San Bernardino	Release and Exchange of Information to Facilitate a Collaborative Approach to the Mental Health Needs of Families in the Child Welfare System	English	cfs000074so
89	San Bernardino	Authorization For Release Of Protected Health Information (PHI)	English	com000001e
90	San Bernardino	Consent To Exchange Confidential Information/Protected Health Information	English	cfs000032cws
91	San Bernardino	Consent For Dependent Routine Outpatient Treatment	English	com000004_1_cfs
92	San Bernardino	Notice Of Privacy Practices	English	com000004cfs
93	San Diego	Order Authorizing Medical Examination And Treatment	English	04-24C
94	San Diego	Consent For Examination And Treatment	English	04-24P
95	San Diego	Authorization To Use Or Disclose Protected Health Information	English	04-29
96	San Francisco	Acknowledgement of Receipt of Materials	English	Acknowledgement of Receipt of Materials
97	San Francisco	Appeal and Grievance Process	English	Appeal and Grievance Process
98	San Francisco	Authorization to Release Information for Billing and Assignment of Benefits	English	Authorization to Release Information for Billing and Assignment of Benefits
99	San Francisco	Authorization for Use or Disclosure of Protected Health Information	English	Authorization for Use or Disclosure of Protected Health Information
100	San Francisco	Consent for Community Behavioral Health Services Mental Health Drug/Alcohol Treatment Programs	English	Consent for Community Behavioral Health Services