Forms

If you would like to obtain a copy of your health records, please complete the attached form:

If you would like to request to have records sent to another facility/person, please complete the attached form:

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:

If you would like to file a Grievance Appeal, please complete the attached form:

Complete the attached form to submit an Adult/Elder Abuse Confidential Report

If you would like to revoke an authorization that was previously requested, please complete the attached form.  The revocation will be active upon receipt at our office for processing.  Incomplete forms may delay processing.