Looking for a U.s. Department Of Health And Human Services Forms And Templates? Download it for free!

Form Dhcs 1802 - Involuntary Patient Advisement - California Department Of Health Care Services

State of California - Health and Human Services Agency

Department of Health Care Services

INVOLUNTARY PATIENT ADVISEMENT

Confidential Patient Information

(TO BE READ AND GIVEN TO THE

See W&I Code Section 5328 and

PATIENT AT TIME OF ADMISSION)

HIPAA Privacy Rule 45 C.F.R. Section 164.508

Name of Facility

Patient’s Name

Admission Date

Section 5150(h) of the Welfare and Institutions Code requires that each person admitted to a facility

designated by the county for evaluation and treatment be given specific information orally and in writing,

and in a language or modality accessible to the person and a record of the advisement be kept in the

person’s medical record.

My name is

My position here is

You are being placed in this psychiatric facility because it is our professional opinion, that as a result of a

mental health disorder, you are likely to: (check applicable)

Harm yourself

Harm someone else

Be unable to take care of

your own food clothing or shelter

(List specific facts upon which the allegation of dangerous or gravely disabled due to mental health disorder is

based, including pertinent facts arising from the admission interview):

We believe this is true because

You will be held for a period of up to 72 hours. This (does not) (does) include weekends or holidays.

Your 72-hour period begins:

(Time and Date)

Your 72-hour evaluation and treatment period will end at:

(Time and Date)

You will be held for a period up to 72 hours. During the 72 hours you may also be transferred to another

facility. You may request to be evaluated or treated at a facility of your choice. You may request to be

evaluated or treated by a mental health professional of your choice. We cannot guarantee the facility or

mental health professional you choose will be available, but we will honor your choice if we can.

During these 72 hours you will be evaluated by the facility staff, and you may be given treatment, including

medications. It is possible for you to be released before the end of the 72 hours. But if the staff decides that

you need continued treatment you can be held for a longer period of time. If you are held longer than 72

hours, you have the right to a lawyer and a qualified interpreter and a hearing before a judge. If you are

unable to pay for the lawyer, then one will be provided to you free of charge.

If you have questions about your legal rights, you may contact the county Patients’ Rights Advocate

at__________________________________ (phone number of county Patients’ Rights Advocacy Office).

Good cause for Incomplete Advisement

Date

Advisement Completed by

Position

Language or Modality Used

Date

CC: Original to the Patient

Carbon to the Patient’s Record

DHCS 1802 (01/2014)

Form Dhcs 1802 - Involuntary Patient Advisement - California Department Of Health Care Services

Related Articles

Related forms

Related Categories