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Clerk stamps date here when form is filed.

JV-229

Withdrawal of Release of
Information to Medical Board of
California
You may use this form to stop your authorization for 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, and to see your medical records.

1 Your information:
I am the

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

b.
c.

d.
e.
f.

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

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 ):

Fill in court name and street address:

Superior Court of California, County of

Court fills in case number when form is filed.

Case Number:

My client’s telephone number:

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

If you want to keep your address or your client’s address confidential in the juvenile court file, fill out Confidential
Information (form JV-287) and do not write the address on this form.

Check here if form JV-287 is attached.

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 or my client for
further details about medical care.

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

I DO NOT 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.

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 CDSS. CDSS must
maintain all forms received.

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

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

Withdrawal of Release of Information to
Medical Board of California

JV-229, Page 1 of 1

Withdrawal of Release of Information to Medical Board of California

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the California state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from selfhelp.courts.ca.gov (2023-03)
Page(s): 1
Fields(s): 26
Average fields per page: 26
Reading Level: Grade 8
LIST Grouping(s): Unknown

Use our Rate My PDF tool to learn more. Go beyond the above insights and learn more about this or any pdf form at RateMyPDF.com, includes: counts of difficult words used, passive voice decetion, and suggestions for how to make the form more usable.

Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

Here are the fields we could identify.

j_page_right_court_info_ft was JV-229[0].Page1[0].RightCaption[0].CourtInfo_ft[0] (0.52 conf)
j_page_right_case_number_ft was JV-229[0].Page1[0].RightCaption[0].CaseNumber_ft[0] (0.36 conf)
j_page_protected_lawyer_name_ft__1 was JV-229[0].Page1[0].ProtectedLawyerName_ft[0] (0.30 conf)
j_v_page_protected_street_ft was JV-229[0].Page1[0].ProtectedStreet_ft[0] (0.36 conf)
j_v_page_protected_phone_ft was JV-229[0].Page1[0].ProtectedPhone_ft[0] (0.32 conf)
j_v_page_protected_lawyer_firm__1 was JV-229[0].Page1[0].ProtectedLawyerFirm_ft[0] (0.32 conf)
j_v_page_protected_email_ft__1 was JV-229[0].Page1[0].ProtectedEmail_ft[0] (0.36 conf)
j_v_page_item_cb__1 was JV-229[0].Page1[0].item1a_cb[0] (0.35 conf)
j_v_page_item_cb__2 was JV-229[0].Page1[0].item1a_cb[1] (0.35 conf)
j_page_protected_lawyer_name_ft__2 was JV-229[0].Page1[0].ProtectedLawyerName_ft[1] (0.30 conf)
j_page_protected_lawyer_name_ft__3 was JV-229[0].Page1[0].ProtectedLawyerName_ft[2] (0.30 conf)
j_v_page_protected_lawyer_firm__2 was JV-229[0].Page1[0].ProtectedLawyerFirm_ft[1] (0.32 conf)
j_v_page_protected_email_ft__2 was JV-229[0].Page1[0].ProtectedEmail_ft[1] (0.36 conf)
j_v_page_item_cb__3 was JV-229[0].Page1[0].item3_cb[0] (0.35 conf)
j_v_page_item_cb__4 was JV-229[0].Page1[0].item3_cb[1] (0.35 conf)
j_v_page_item_cb__5 was JV-229[0].Page1[0].item1a_cb[2] (0.35 conf)
j_v_page_party_signature_dt was JV-229[0].Page1[0].PartySignature_dt[0] (0.33 conf)
j_v_page_party_name_ft was JV-229[0].Page1[0].PartyName_ft[0] (0.30 conf)
j_v_page_signature_cb__1 was JV-229[0].Page1[0].signature_cb[0] (0.35 conf)
j_v_page_signature_cb__2 was JV-229[0].Page1[0].signature_cb[1] (0.35 conf)
j_v_page_signature_cb__3 was JV-229[0].Page1[0].signature_cb[2] (0.35 conf)
j_v_page_check_box_right was JV-229[0].Page1[0].CheckBoxRightCaption[0] (0.39 conf)
j_v_page_item_cb__6 was JV-229[0].Page1[0].item4_cb[0] (0.35 conf)
j_v_page_item_cb__7 was JV-229[0].Page1[0].item4_cb[1] (0.35 conf)
j_v_page_item_cb__8 was JV-229[0].Page1[0].item5_cb[0] (0.35 conf)
j_v_page_item_cb__9 was JV-229[0].Page1[0].item5_cb[1] (0.35 conf)

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The Legal Innovation & Technology Lab's Form Explorer Beta @ Suffolk Law School Last updated 2023-04-02

Withdrawal of Release of Information to Medical Board of California

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Identified Data Fields:

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The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02