JV-228

Position on Release of Information 
to Medical Board of California

Clerk stamps date here when form is filed.

Fill in court name and street address:

Superior Court of California, County of

My name:
My address, city, state, and zip code (If confidential, see      ):

2

Court fills in case number when form is filed.

Case Number:

You have been prescribed three or more psychotropic medications at the same 
time for 90 days or longer. The Medical Board of California will look into the 
care your doctor provided you and may need additional information to decide 
if the doctor properly prescribed medication for you. You may use this form to 
authorize the California Department of Social Services and the California 
Department of Health Care Services to give your name and contact information 
to the Medical Board of California, if the board requests, so the board can look 
more closely at your care. You can also use this form to authorize the release 
of limited information to the board.

1 Your information:
I am the

a.

child or youth
nonminor dependent
child’s or youth’s attorney

My telephone number:

My email address:
If you are an attorney:
My client’s name:
My client’s address, city, state, and zip code (If confidential, see      ):

2

My client’s telephone number:
My client’s email address:
My state bar number:

If the child or nonminor dependent’s address should remain confidential in the juvenile court file, a Confidential 
Information (form JV-287) must be completed. The address should not be included on this form.

Check here if form JV-287 is attached. 

I understand that I cannot be denied the receipt of government services or treatment, and care may not be denied due 
to not authorizing the release of information.

      I authorize            my name and contact information           my client’s name and contact information      to 
be shared with the Medical Board of California and authorize board staff to contact           me 
      my client for further details about medical care.

      I do not authorize           my name and contact information           my client’s name and contact information    
to be shared with the Medical Board of California and do not authorize board staff to contact           me  
      my client for further details about medical care.

If you check item 4b, you can skip to the signature line at the end of this form.

Judicial Council of California, www.courts.ca.gov 
New September 1, 2020, Optional Form 
Welfare and Institutions Code, §§ 369.5, 739.5, 14028 
California Rules of Court, rules 5.640 and 5.642

Position on Release of Information to 
Medical Board of California

JV-228, Page 1 of 2

b.

c.

d.

e.
f.

a.

b.

2

3

4

Case Number:

5

a.

      I authorize the California Department of Health Care Services and the California Department of Social 
Services to connect           my name            my client’s name     to the prescribing data and other information 
about          me            my client     that was previously provided under a unique number.

b.

      I do not authorize the California Department of Health Care Services and the California Department of 
Social Services to connect          my name          my client’s name     to the prescribing data and other 
information about           me           my client     that was previously provided under a unique number.

6

a.

I authorize the Medical Board of California to see          my           my client’s    medical records to decide if 
there are any potential violations of the law or excessive prescribing of psychotropic medications. 

(1)

(2)

(3)

The authorization is limited to medical information relevant to the investigation of the prescription of 
psychotropic medications only. 

The information may be used only for the purpose of the investigation.

If the medical information is admitted as an exhibit in an administrative hearing, the medical board must 
request that it be sealed.

b.

I do not authorize the Medical Board of California to obtain           my           my client’s     medical records 
to decide if there are any potential violations of the law or excessive prescribing  of psychotropic 
medications.

This authorization will remain valid for three years unless I cancel it in writing by using Withdrawal of Release of 
Information to Medical Board of California (form JV-229).

This form does not authorize the release of juvenile court case file information as described by Welfare and 
Institutions Code section 827.

I understand that I may cancel this authorization by filing Withdrawal of Release of Information to Medical Board 
of California (form JV-229).

7

8

9

Date:

Type or print your name

Signature of

Child or youth
Nonminor dependent
Attorney for child, youth, or nonminor dependent

Whenever a child, nonminor dependent, or attorney signs this form, the child or nonminor dependent’s attorney must 
file the form with the juvenile court. The clerk of the court must mail a copy of the form to the California Department 
of Social Services (CDSS). CDSS must maintain all forms received to review whether the child has given permission 
to release their information to the Medical Board of California.  

California Department of Social Services 
Attention: Information Release for California Medical Board 
744 P Street, MS 8-13-66 
Sacramento, CA 95814

New September 1, 2020

Position on Release of Information to  
Medical Board of California

JV-228, Page 2 of 2