Behavioral Health Links (CalAIM Justice-Involved Behavioral Health Records Request)

Behavioral Health Links (CalAIM Justice-Involved Behavioral Health Records Request)
Use this form to request medical/behavioral health records for an individual currently or recently incarcerated at your facility AND eligible for services under the CalAIM Justice-Involved initiative. The information you provide will be forwarded to the Marin County medical records department and they may contact you if they need any additional information before releasing records to your agency.
Requesting Party
Name*

First NameLast Name
Title/Position*
Agency/Correctional Facility*
Email address*
example@example.com
Phone Number*
Please enter a valid phone number.
Alternative contact if different than the person submitting this request
Justice-Involved Individual
Full Name*

First NameLast Name
Any known aliases
Date of Birth*

MonthDayYear
Medi-Cal ID number*
Client Identification Number/Social Security Number
Known or estimated release date*

MonthDayYear
Requesting medical records from BHRS is accomplished using the HIPAA compliant forms available in PDF format below. Forms require an ink signature.

Release of Information - English (PDF)

Release of Information - Spanish (PDF)

Release of Information - Vietnamese (PDF)
Upload a signed ROI*

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