Get Data Extract Request Form And Oath Of Confidentiality - La County ... - Lacdmh Lacounty

This guide provides clear, step-by-step instructions for completing the Data Extract Request Form and Oath of Confidentiality for Los Angeles County. Designed for individuals with varying levels of experience, this resource will help you navigate the form with confidence.

Follow the steps to successfully complete your request.

1. Click the ‘Get Form’ button to access the Data Extract Request Form and open it in your preferred editing tool.
2. In the 'Request Type' section, select one of the following options: New, Renewal, or Delete. Ensure that you mark only one box to indicate your request type accurately.
3. Fill out the 'Applicant Information' section. This includes your full name, last four digits of your social security number, date of birth, logon ID, legal entity or provider number, legal entity provider name, telephone number, and email address.
4. In the 'Requesting' section, indicate whether you are requesting download access, upload access, and ensure to check the box for 'Confidential Oath & AUP Attached' if applicable.
5. Provide the details for the 'Authorization' section by entering the authorized CEO or designee’s name, signature, and date completed. This verifies that you have permission to access the requested data.
6. Make sure to include the contact person's details, including their name, phone number, and email address, in case further information is needed.
7. After reviewing the entire form for completeness and accuracy, print the form to provide the required original signatures as indicated in the instructions.
8. Finally, save your changes, then download, print, or share the completed form as necessary before submitting it to the Department of Mental Health at the specified address.

Start filling out your Data Extract Request Form and Oath of Confidentiality online today to ensure efficient processing.