Get San Joaquin County Behavioral Health Services Client Name File ... - Sjgov

This guide provides a clear and instructive approach to filling out the San Joaquin County Behavioral Health Services Client Name File form online. By following the steps outlined below, you can ensure that you accurately complete the necessary fields and submit the authorization effectively.

Follow the steps to fill out the form correctly.

1. Press the ‘Get Form’ button to access the form and open it for completion.
2. Begin by entering the patient/client's name in the designated field. Make sure to provide the full legal name.
3. Input the date of birth (DOB) and the Social Security Number (SSN) in their respective fields to ensure proper identification.
4. If applicable, list any maiden names or other names previously used by the patient/client.
5. Indicate the dates of treatment that are covered by this authorization in the provided fields.
6. Fill in the name and contact details of the healthcare provider or agency from whom information is being requested.
7. Specify the recipient's name and address to whom the information will be disclosed.
8. State clearly the purpose for which the records are being requested, choosing from options such as personal records or continuing healthcare.
9. Select the information types to be released by checking all applicable boxes, such as evaluations or lab reports.
10. If necessary, provide details for any other forms that need to be completed along with the authorization.
11. Grant special authorization if applicable by checking the relevant boxes regarding specific sensitive information.
12. List any exceptions of information that should not be released, if necessary.
13. Sign and date the authorization at the bottom of the form. If a legal representative is signing, include their relationship to the patient/client.
14. Once completed, save your changes, and you may choose to download, print, or share the form as needed.

Complete your documents online today for timely processing.