All homeowners in California are required to file a form MH 5671 when they sell their home. This form is used to report the sale of a principal residence and any capital gains or losses that were realized as a result of the sale. The deadline for filing this form is April 15th, and it must be submitted electronically. In order to complete the form, you will need information about the purchase price, date of purchase, and sale price of your home. You will also need to calculate your adjusted basis and gain or loss on the sale. If you have any questions about how to complete the form, please consult with a tax professional.
| Question | Answer |
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| Form Name | California Form Mh 5671 |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names |
State of California - Health and Human Services Agency |
Department of Mental Health |
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AUTHORIZATION FOR RELEASE |
Confidential Patient Information |
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OF PATIENT INFORMATION |
See W&I Code Section 5328 and |
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MH 5671 (Rev. 06/08) Page 1 of 3 |
HIPAA Privacy Rule CFR Section 164.508 |
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INSTRUCTIONS: Use this form to obtain the required authorization when a request is received for patient information, unless the request received is a facsimile of this form or contains all of the required information. Obtain signature of patient or parent/guardian/ conservator. If patient signs, obtain “witness signature.” List the information released per this authorization on the back of this form.
The hospital shall not condition treatment or payment based on this authorization. The patient may refuse to sign the authorization. If the authorization is not signed, the information shall not be released except when required by law. Upon request, the patient may inspect or be provided a copy of the protected health information to be disclosed by this authorization.
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Patient’s Name |
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Birth Date |
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Month Day Year |
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I, |
and/or |
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Name of Patient |
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Name of Parent/Guardian/Conservator |
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hereby authorize
Name of Agency/Person/Organization
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Address (Street, City, State and Zip Code)
to release to
Name of Agency/Person/Organization
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Address (Street, City, State and Zip Code)
the information specified on Page 2 of this form with the knowledge that such release discloses the fact that mental health services have been/are being provided.
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State of California - Health and Human Services Agency |
Department of Mental Health |
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AUTHORIZATION FOR RELEASE |
Confidential Patient Information |
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OF PATIENT INFORMATION |
See W&I Code Section 5328 and |
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MH 5671 (Rev. 06/08) Page 2 of 3 |
HIPAA Privacy Rule C.F.R. Section 164.508 |
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This disclosure of information* is required for the following purpose(s): (initial applicable
areas) |
Evaluation |
Treatment Planning/Course |
Other (Specify) __________ |
and shall be limited to releasing the following types of information (initial all applicable areas): from (date required) __________________to (date required) __________________;
or any information/records indicated, regardless of date.
Entire Record
Diagnosis
Psychiatric Evaluation
Discharge Summary
Social History
Individual Treatment
Plan
Legal Information
Medical, Neurological
Assessment, Lab Tests,
e.g., EEG, EKG, etc.
Seclusion and/Restraint Information
HIV Tests Results
Other Evaluations/ Assessments (specify)
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Results of Psychological/ Vocational Testing Conference(s) Date(s)
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Other (specify)
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*The information disclosure under this authorization may be subject to
(Month/Day/Year) ___. This authorization may be revoked in writing by the
undersigned at anytime except to the extent that action has already been taken. If not
revoked, it shall terminate at the end of (check one): |
6 months |
One year or |
Specify Date ____________________. |
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I understand that I am to receive a copy of this authorization.
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Date: |
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Signature of Patient |
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Month |
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Year |
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Date: |
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Signature of Parent/Guardian/Conservator, if Applicable |
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Day |
Year |
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Date: |
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Witness Signature |
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Day |
Year |
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Signature of Professional* |
Date |
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Person Obtaining Authorization Date |
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*Professional for this authorization refers only to a Physician, Licensed Psychologist or Social Worker with a Master’s degree in social work, or Marriage and Family Therapist who approves this patient initiated request for release of patient records.
State of California - Health and Human Services Agency |
Department of Mental Health |
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AUTHORIZATION FOR RELEASE |
Confidential Patient Information |
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OF PATIENT INFORMATION |
See W&I Code Section 5328 and |
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MH 5671 (Rev. 06/08) Page 3 of 3 |
HIPAA Privacy Rule C.F.R. Section 164.508 |
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RECORD OF RELEASE OF INFORMATION
The following information was released to the named party specified on the front of this form. Identify the specific dates of the reports, records, items released.
Entire Record
Diagnosis
Psychiatric Evaluation
Discharge Summary
Social History
Individual Treatment Plan
Other:
Legal Information
Medical, Neurological Assessment, Lab Tests, e.g., EEG, EKG, etc.
HIV Tests Results
Results of Psychological/ Vocational Testing
Other Evaluations/ Assessments (specify)
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____________________
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Conference(s) Date(s)
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____________________
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Released By (Name & Title) |
Date Released |
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