Record Request
This form may only be used by entities providing health care in correctional facility in California. The requestor must have the right to request this information as per the justice involved requirements of care coordination.
Requestor Name
*
First Name
Last Name
Requestor email
*
example@example.com
Name of Correctional Facility
Requesting County
Please Select
Alameda
Alpine
Amador
Butte
Calaveras
Colusa
Contra Costa
Del Norte
El Dorado
Fresno
Glenn
Humboldt
Imperial
Inyo
Kern
Kings
Lake
Lassen
Los Angeles
Madera
Marin
Mariposa
Mendocino
Merced
Modoc
Mono
Monterey
Napa
Nevada
Orange
Placer
Plumas
Riverside
Sacramento
San Benito
San Bernardino
San Diego
San Francisco
San Joaquin
San Luis Obispo
San Mateo
Santa Barbara
Santa Clara
Santa Cruz
Shasta
Sierra
Siskiyou
Solano
Sonoma
Stanislaus
Sutter
Tehama
Trinity
Tulare
Tuolumne
Ventura
Yolo
Yuba
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Client Information
Name
*
First Name
Last Name
Birthdate
-
Month
-
Day
Year
Date
Release of Information link coming soon.
Medication Summary
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Treatment Summary
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Release of Information
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By submitting this form, I declare the client has consented to share these records or is doing so under care coordination.
*
Yes
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