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
Confidential Patient Information
See W&I Code Section 5328 and
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
Advisement Completed by
Language or Modality Used
CC: Original to the Patient
Carbon to the Patient’s Record
DHCS 1802 (01/2014)


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