Form 1127-A California San Bernardino 2017-2025

Form 1127-A California San Bernardino: What You Should Know

California Department of Behavioral Health Disclosure Statement (PDF) (PDF) Department of Behavioral Health Policy Statement (PDF) (PDF) Consultation with California Department of Behavioral Health Disclosure Statement Staff prior to requesting the form is highly recommended  I. DISCLAIMER To:  “The Department of Behavioral Health (dB) is in the business of serving children and adults with behavioral disorders (children and adults), and is concerned about the best interests of families and society generally. By providing services to children and to adults, DEBT, as a publicly financed agency, has the responsibility for compliance with state, federal, and other law protecting the confidentiality and integrity of individuals in receipt of services and maintaining the confidentiality and integrity of the DEBT, DEBT clients, DEBT facilities, and persons and property in DEBT, DEBT facilities, its service areas, and DEBT's records. To make the disclosure statement and to provide written copies to the requesting person or persons upon request or upon the occurrence of a breach of the statement are reasonable and appropriate conduct for persons and persons and persons and property in DEBT. Disclosure of certain information in the disclosure statement is required in accordance with applicable law and DEBT's policies and procedures.” II. PRIVACY POLICY STATEMENT DHA's policies and procedures regarding the use of its name (or initials) in association with the disclosure statement and providing written copies of the disclosure statement to persons and persons and property in DEBT are as follows: DHA has determined that the use of the DHA name in and of itself does not violate public policy. In addition, DHA considers that the disclosure statement, when submitted to any person or persons and property in DEBT, DEBT facilities, its service areas, and DEBT's records, may be used in accordance with state, federal, and other law protecting the confidentiality and integrity of individuals in receipt of services and maintaining the confidentiality and integrity of the DHA, DHA clients, DHA facilities, its service areas, and DHA's records. II. DISCLOSURE STATEMENT The following is DHA's most recent disclosure statement from December 23, 2017: We have been unable to obtain adequate information with the Department of Social Services to identify you as a resident of the DHA. Therefore, we are unable to give you the information in the disclosure statement relating to your living situations and/or family situations.

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