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Join us on september 27 @ UCLA
Click Here For More Details!
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Documents for care, coverage, and support
Easily manage your care online through our secure Client Portal. Log in to complete forms, request records, update information, and stay connected with your care team.
Financial Obligation Agreement
Financial Obligation Agreement (Spanish)
Financial Obligation Agreement (Armenian)
Insurance Authorization and Assignment of Benefits Form
Lifetime Extended Signature Authorization
SPC Counseling Credit Card Authorization Form
SPC Counseling Good Faith Estimate
SPC Counseling Insurance Authorization and Assignment of Benefits
Accounting of Disclosures Request
Authorization For Request Or Use Disclosure Of Protected Information
Authorization For Request Or Use Disclosure Of Protected Information (Spanish)
Didi Hirsch Notice of Privacy Practices
Didi Hirsch Notice of Privacy Practices (Spanish)
Request to Amend Client Record
Statement of Disagreement with Amendment Request Determination
Didi Hirsch Client Grievance Form or file a grievance directly: File a complaint or grievance
Grievance Policy (for Suicide Prevention Center Counseling)
Orange County Grievance or Appeal Form for SPC Counseling (English)
Orange County Grievance or Appeal Form for SPC Counseling (Spanish)
Request of Change of Provider (for Suicide Prevention Center Counseling)
Request of Change of Provider (for Suicide Prevention Center Counseling) (SPANISH)
SPC Crisis Line: Grievance Policy (for Suicide Prevention Center Crisis Line)
Teen Line: Complaint & Grievance Form (for Teen Line)
Accounting of Disclosures Request
Authorization For Request Or Use Disclosure Of Protected Information
Authorization For Request Or Use Disclosure Of Protected Information (Spanish)
Didi Hirsch Notice of Privacy Practices
Didi Hirsch Notice of Privacy Practices (Spanish)
Behavioral Health Member Handbook
Request to Amend Client Record
Statement of Disagreement with Amendment Request Determination
Advanced Healthcare Directive Fact Sheet
Advanced Healthcare Directive Fact Sheet (Spanish)
Caregiver’s Authorization Affidavit
Caregiver’s Authorization Affidavit (Spanish)
Consent To Photograph Audio, Record Display Art Work
Notice of Open Payments Database
Substance Use Treatment Program Description and Admission Criteria
Accounting of Disclosures Request
Behavioral Health Member Handbook
Beneficiary Non-Discrimination Notice (for Substance Use Treatment)
Client Rights (for Substance Use Treatment)
Notice of Privacy Practices (for Substance Use Treatment)
Notice of Privacy Practices (for Substance Use Treatment) (Spanish)
Request to Amend Client Record
SAPC Patient Access System Resources
SAPC Payment and Operations ROI
SAPC Treatment and Care Coordination ROI
Statement of Disagreement with Amendment Request Determination
Accounting of Disclosures Request
Authorization For Request Or Use Disclosure Of Protected Information
Authorization For Request Or Use Disclosure Of Protected Information (Spanish)
Didi Hirsch Notice of Privacy Practices
Didi Hirsch Notice of Privacy Practices (Spanish)
Request to Amend Client Record
Statement of Disagreement with Amendment Request Determination
Didi Hirsch Client Grievance Form or file directly: File a complaint or grievance
Refer to Health Plan: L.A. CARE, Health Net, Molina Healthcare
Accounting of Disclosures Request
Authorization For Request Or Use Disclosure Of Protected Information
Authorization For Request Or Use Disclosure Of Protected Information (Spanish)
Didi Hirsch Notice of Privacy Practices
Didi Hirsch Notice of Privacy Practices (Spanish)
Request to Amend Client Record
Statement of Disagreement with Amendment Request Determination
Didi Hirsch Client Grievance Form or file a grievance directly: File a complaint or grievance
To request your Didi Hirsch records or share them with another provider, please contact our Release of Records team. While requests are not initiated directly in the Client Portal, our staff will guide you through the process to ensure your information is handled securely.
For your convenience, we can make your completed documents available digitally through the Client Portal, or we can provide them via the delivery method specified in your request (such as email, mail, or in-person pickup).
There are a few different ways you can make a Records Request:
Visit our Resources page for easy access to links, downloads, guides, and other materials to support your care journey.
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