Sp 66 Form PDF Details

The SP 66 form is a critical document within the state of New Jersey, serving as a consent form for the mental health records search required for firearm applicants. Its importance stems from laws that protect the confidentiality of an individual's mental health records, while also balancing public safety concerns regarding firearm ownership. New Jersey Statutes Annotated 30:4-24.3 underscores the confidential nature of mental health commitments, allowing disclosure only under specific circumstances or with the individual's consent. This form explicitly includes a section where the applicant acknowledges their understanding of these privacy laws and consents to the release of their mental health records for the purpose of firearm permit application assessment. It demands thorough personal information, including past addresses and a voluntary social security number, to expedite application processing. The document also outlines the process for verifying the information provided, involving the Chief of Police, Superintendent of State Police, or their designees, who assess the applicant's fitness to own a firearm. The inclusion of possible expunged records in the disclosure further emphasizes the thoroughness of the background check. Additionally, the form accommodates records from any mental health institution or doctor involved in the applicant's treatment, which ensures a comprehensive review of the applicant's mental health history. This consent form demonstrates the delicate balance between individual privacy rights and public safety concerns, specifically tailored to the process of firearm ownership application in New Jersey.

QuestionAnswer
Form NameSp 66 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesnj mental health form, nj sp mental health form, njsp sp 66 form, njsp sp 66

Form Preview Example

 

CONSENT FOR

 

 

 

N.J.S.A. 30:4-24.3 provides that all records

 

 

 

 

of any individual's commitment to a non-

 

 

 

 

 

 

 

MENTAL HEALTH RECORDS SEARCH

 

correctional

institution for mental health

 

reasons shall be confidential and shall not

This consent MUST be completed by the firearm applicant.

 

 

be disclosed except in limited circumstanc-

Failure to consent requires denial or disapproval of the application.

 

 

es or with the consent of the individual.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART ONE (To be completed by the applicant)

 

 

 

 

 

 

 

Name: (Last, Maiden, First, MI)

 

 

 

 

Date of Birth: (Month, Day, Year)

Social Security #: *See Privacy Act Notice Below.

 

 

 

 

 

 

 

 

 

 

 

Address: (Number & Street)

 

 

 

(Municipality)

 

(County)

 

(State)

 

 

 

 

 

 

 

 

 

 

List Prior Addresses for past 10 years:

 

NOT APPLICABLE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS 1: Dates Resided

From: ________________________

To: ________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Number & Street)

 

 

 

(Municipality)

 

(County)

 

(State)

 

 

 

 

 

 

 

 

 

ADDRESS 2: Dates Resided

From: ________________________

To: ________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Number & Street)

 

 

 

(Municipality)

 

(County)

 

(State)

 

 

 

 

 

 

 

 

 

 

 

I, __________________________________________________ am aware of my rights under N.J.S.A. 30:4-24.3, and the

Health Insurance Portability and Insurance Accountability Act (HIPAA), 45 C.F.R. 164-50, and consent to the disclosure of my mental health records, including disclosure of the fact that said records may have been expunged, to the Chief of Police and the Superintendent of State Police, or their designees, for the purpose of verifying my firearms permit application and my fitness to own a fi rearm under N.J.S.A. 2C:58-3. I understand that copies of this authorization shall be considered

suffi cient authorization for the release of records or for the disclosure of the fact of expungement.

Investigating Police Department

Witness (Print Name)

X

Signature of Applicant

X

Signature of Witness

Date

*Applicant's Social Security Number is requested pursuant to N.J.S.A. 2C:58-3(e) and disclosure is voluntary. The number will be used to expedite the application. Without this number, the processing of the application may be delayed. This number is considered confidential.

PART TWO (To be completed by County Adjuster's Office, Mental Health Institution and/or Doctor)

 

Record of Admission

Date of

Signature of Authorized

 

Commitment or Treatment

Check

Official or Doctor

 

 

 

 

 

(Dr.: Provide Medical License #)

__________________________________________________

Yes

No

Expunged

______________

________________________

County Adjuster's Office

 

 

 

 

 

__________________________________________________

Yes

No

Expunged

______________

________________________

Institution or Doctor

 

 

 

 

 

PART THREE (To be completed by authorized official or doctor only if applicant has record of admission, commitment, or treatment at a hospital, mental institution or sanitarium for a mental disorder)

NAME OF HOSPITAL, MENTAL INSTITUTION

ADMISSION

 

DISCHARGE

SIGNATURE OF AUTHORIZED

OR SANITARIUM

(mo/day/yr)

 

(mo/day/yr)

OFFICIAL OR DOCTOR

__________________________________________

____________

to

____________

____________________________________

__________________________________________

____________

to

____________

____________________________________

 

Additional forms may be obtained through the New Jersey State Police, Firearms Investigation Unit,

S.P. 66 (Rev. 01/15)

P.O. Box 7068, West Trenton, NJ 08628-0068, or via the internet at www.njsp.org/info/forms.html.

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1. Begin completing your sp66 form with a number of essential blanks. Consider all the necessary information and be sure absolutely nothing is overlooked!

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2. Soon after this selection of blank fields is done, proceed to type in the relevant information in these - I am aware of my rights under, Investigating Police Department, X Signature of Applicant, Witness Print Name, X Signature of Witness, Date, Applicants Social Security Number, Without this number the processing, PART TWO To be completed by County, County Adjusters Office, Record of Admission, Commitment or Treatment, Date of Check, Signature of Authorized, and Official or Doctor.

Stage # 2 in submitting sp 66 form

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