Cal. Code Regs. Tit. 22, § 84172 - Personal Rights
(Name of the Facility) ____________________ day of __________ 20 _____
I, ________________________________________ (member of the community treatment facility staff) have today received a request for the release of ______________________________ (name of patient) from the undersigned patient on their own behalf or from the undersigned person on behalf of the patient.
Signature or mark of patient making request for release
Signature or mark of patient making request for release on behalf of patient
Signature of staff person receiving request for release
Notes
Note: Authority cited: Sections 1530, 1530.9 and 1530.91, Health and Safety Code. Reference: Sections 1501, 1512, 1530.91 and 1531, Health and Safety Code; and Sections 4096(g), 4094.6, 5275 and 16001.9, Welfare and Institutions Code.
Note: Authority cited: Sections 1530 and 1530.9, Health and Safety Code. Reference: Sections 1501, 1530.91 and 1531, Health and Safety Code; and Sections 4096(g), 4094.6, 5275 and 16001.9, Welfare and Institutions Code.
2. Amendment of subsection (b) and Note filed 8-16-2004; operative 9-15-2004 (Register 2004, No. 34).
3. Amendment of section and Note filed 3-1-2024; operative
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(Name of the Facility) _______________ day of _____ 19 _____
I, ____________________ (member of the community treatment facility staff) have today received a request for the release of _______________ (name of patient) from the undersigned patient on his or her own behalf or from the undersigned person on behalf of the patient.
___________________________ | |
Signature or mark of patient making request for release | |
___________________________ | |
Signature or mark of patient making request for release on behalf of patient | |
___________________________ | |
Signature of staff person receiving request for release |
Notes
2. Amendment of subsection (b) and NOTE filed 8-16-2004; operative 9-15-2004 (Register 2004, No. 34).
Note: Authority cited: Sections 1530 and 1530.9, Health and Safety Code. Reference: Sections 1501, 1530.91 and 1531, Health and Safety Code; and Sections 4096(g), 4094.6, 5275 and 16001.9, Welfare and Institutions Code.
2. Amendment of subsection (b) and Note filed 8-16-2004; operative 9-15-2004 (Register 2004, No. 34).