Form Dhcs 1808 - California Notice Of Certification - Health And Human Services Agency

ADVERTISEMENT

State of California - Health and Human Services Agency
Department of Health Care Services
NOTICE OF CERTIFICATION
Confidential Patient Information
HIPAA Privacy Rule
See Welfare & Institutions Code
45 C.F.R. § 164.508
Section 5328 and Penal Code 11142
The authorized agency providing evaluation services in the County of
has evaluated the condition of:
Name ___________________________________________________________________________________________________
Address _________________________________________________________________________________________________
Marital Status ___________________________
Date of Birth
Sex __________
We, the undersigned, allege that the above-named person is, as a result of a mental disorder or impairment by chronic alcoholism
(Mark all that apply):
A danger to others
A danger to himself or herself
Gravely disabled as defined in paragraph (1) of sub-
division (h) or subdivision (1) of Section 5008 of
the Welfare and Institutions Code
*Strike out all inapplicable classifications.
The specific facts which form the basis for our opinion that the above-named person meets one or more of the classifications indicat-
ed above are as follows:
The above-named person has been informed of this evaluation, and has been advised of the need for, but has not been able or willing
to accept treatment on a voluntary basis, or to accept referral to, the following services:
We, therefore, certify the above-named person to receive intensive treatment related to the mental disorder or impairment by chronic
alcoholism beginning this ____________________ day of _______________________, 20______ , in the intensive treatment facility
herein named ______________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________
Date
Signature ________________________________________________________________________________________________
Signature ________________________________________________________________________________________________
I hereby state that I delivered a copy of this notice this day to the above-named person and that I informed him or her that unless judicial
review is requested, a certification review hearing will be held within four days of the date on which the person is certified for a period
of intensive treatment and that an attorney or advocate will visit him or her to provide assistance in preparing for the hearing or to an-
swer questions regarding his or her commitment or to provide other assistance. The court has been notified of this certification on this
day.
Signature ________________________________________________________________________________________________
Copies: Person Certified-Personally delivered
Person’s Attorney/Advocate
DHCS 1808 (06/2013)

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go