Forms

If you would like to obtain a copy of your mental health records, please complete the attached form and either mail it to Placer County Medical Records, 101 Cirby Hills Drive, Roseville, CA 95678 or send it to [email protected]:

  1. HIPAA 07 Patient Access to Health Records Request (PDF)
  2. HIPAA 08 Patient Access to Health Records Request-Spanish (PDF)

If you would like to request to have mental health records sent to another facility/person, please complete the attached form and either mail it to Placer County Medical Records, 101 Cirby Hills Drive, Roseville, CA 95678 or send it to [email protected].

  1. HIPAA 05 Release of Information (PDF)
  2. HIPAA 06 Release of Information - Spanish (PDF)

If you would like to request a Change of Service Provider or a Second Opinion within the Placer County Adult System of Care, please complete the attached form and mail it to Placer County Adult System of Care, 101 Cirby Hills Drive, Roseville, CA 95678.

  1. CARE084 Request for Change of Service Provider - Second Opinion English (PDF)
  2. CARE084sp Request for Change of Service Provider - Second Opinion Spanish (PDF)

If you would like to file a Grievance Appeal, please complete the attached form and mail it to Placer County Adult System of Care, 101 Cirby Hills Drive, Roseville, CA 95678.

  1. CARE020 Grievance Appeal Form (PDF)
  2. CARE020sp Grievance Appeal Form Spanish (PDF)

Complete the attached form to submit an Adult/Elder Abuse Confidential Report.  Completed forms can be faxed to Adult Intake at 530-265-9376 or mailed to APS 101 Cirby Hills Drive, Roseville, CA 95678

  1. Report Form SOC341 (PDF)
  2. Financial Institution Report Form SOC342 (PDF)

If you would like to revoke an authorization that was previously requested, please complete the attached form and mail it to Placer County Adult System of Care, 101 Cirby Hills Drive, Roseville, CA 95678 or send it to [email protected].  The revocation will be active upon receipt at our office for processing.  Incomplete forms may delay processing.

  1. Client Authorization Revocation (PDF)
  2. Client Authorization Revocation - Spanish (PDF)