(Name of the state hospital, developmental center, community care facility, or health facility or regional center) ____ day of ____ 19__
I, ____ (member of the staff of the state hospital, developmental center, community care facility, or health facility or employee of the regional center), have today received a request for the release from ____ (name of state hospital, developmental center, or community care facility) State Hospital, developmental center, community care facility, or health facility of ____ (name of patient) from the undersigned patient on his or her own behalf or from the undersigned person on behalf of the patient.
_____ | |
_____ | Signature or mark of patient making request for release |
_____ | |
_____ | Signature or mark of person making request on behalf of patient |
Ca. Welf. and Inst. Code § 4800