For Office Use Only: County of San Bernardino Department of Behavioral Health Simon # PATIENTS RIGHT 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the 'Client Name' and 'Date' at the top of the form. Ensure that you print or write clearly for legibility.
3. Indicate whether you are using an Authorized Representative by selecting 'Yes' or 'No'. If 'Yes', provide their name and phone number.
4. Fill in your 'Date of Birth', 'Gender', and 'Preferred Language'. This information is crucial for accurate processing.
5. Complete your 'Home Address', including city and zip code, followed by your phone number.
6. Specify your 'Clinic or Provider' and describe your grievance in detail in the provided section.
7. State how you would like to see things resolved, ensuring clarity in your request.
8. Sign and date the form at the bottom as a confirmation of your submission.

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