Fillable Declaration Regarding Protection Of Mental Health Record (Page 2 of 2) in pdf

Declaration Regarding Protection Of Mental Health Record Page 2

Download a blank fillable Declaration Regarding Protection Of Mental Health Record in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Declaration Regarding Protection Of Mental Health Record with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

6. The employee has designated the following physician, within the definition of Labor Code § 3209.3 or a health

care provider as defined in Health and Safety Code § 123105, for alternate service of the employee’s copy of this

record:

Name:

Address:

Phone:

Fax:

Medical license no. (CA, if known):

Date of employee designation of this physician or health care provider:

(MM/DD/YYYY)

7. For the above reasons, in response to the employee’s request of _____________________(date MM/DD/YYYY)

for a copy of the record, I responded in the following manner: (Check one below, as appropriate.)

I declined to allow the employee to personally inspect or receive a copy of the record.

I declined to allow the employee to personally inspect, receive a copy or to be served personally

with a copy of the record. However, at the employee’s request, I did provide to,

or serve a copy of

the record on, the physician or health care provider designated by the employee as noted below:

Name:

Address:

Phone:

Fax:

Date of Service:

Manner of Service: (mail, overnight mail, courier, fax)

8. From this time forward, I shall note in the medical file for this employee each time any licensed physician, within

the definition of Labor Code 3209.3 or a health care provider as defined in Health and Safety Code § 123105,

requests to inspect or copy this record on behalf of the employee.

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Date signed:

(Signature)

(Print name)

Address:

Phone:

File record of requests for copies of the attached record made subsequent to the declaration date above:

Date

Person

License type and License number

QME Form 121

Rev. February 2009

Declaration Regarding Protection Of Mental Health Record Page 2

Related Articles

Related forms

Related Categories