PART ONE (To be completed by the applicant)
CONSENT FOR
MENTAL HEALTH RECORDS SEARCH
This consent MUST be completed by the firearm ap pli cant.
Failure to consent requires denial or dis ap prov al of the application.
N.J.S.A. 30:4-24.3 provides that all records
of any individual's commitment to a non-
correctional in sti tu tion for mental health
reasons shall be con fi den tial and shall not
be disclosed ex cept in lim it ed circumstanc-
es or with the consent of the in di vid u al.
I, __________________________________________________ am aware of my rights under N.J.S.A. 30:4-24.3, and the
Health Insurance Portability and Insurance Accountability Act (HIPAA), 45 C.F.R. 164-50, and consent to the disclosure of
my mental health records, including disclosure of the fact that said records may have been expunged, to the Chief of Police
and the Su per in ten dent of State Police, or their designees, for the purpose of verifying my fi rearms permit application and
my fi t ness to own a fi re arm under N.J.S.A. 2C:58-3. I understand that copies of this authorization shall be considered
suffi cient authorization for the release of records or for the disclosure of the fact of expungement.
Name: (Last, Maiden, First, MI) Date of Birth: (Month, Day, Year)
Address: (Number & Street) (Municipality) (County) (State)
NAME OF HOSPITAL, MENTAL INSTITUTION ADMISSION DISCHARGE SIGNATURE OF AUTHORIZED
OR SANITARIUM (mo/day/yr) (mo/day/yr) OFFICIAL OR DOCTOR
__________________________________________ ____________ to ____________ ____________________________________
__________________________________________ ____________ to ____________ ____________________________________
S.P. 66 (Rev. 01/15)
PART TWO (To be completed by County Adjuster's Office, Mental Health Institution and/or Doctor)
PART THREE (To be completed by authorized official or doctor only if applicant has record of admission,
commitment, or treatment at a hospital, mental institution or sanitarium for a mental disorder)
__________________________________________________
__________________________________________________
Record of Admission
Commitment or Treatment
Date of
Check
Signature of Authorized
Official or Doctor
(Dr.: Provide Medical License #)
Yes
No
Expunged
Yes
No
Expunged
______________ ________________________
______________ ________________________
List Prior Addresses for past 10 years:
NOT APPLICABLE
Witness (Print Name)Investigating Police Department
DateSignature of Applicant
X
Social Security #:
*See Privacy Act Notice Below.
(Number & Street) (Municipality) (County) (State)
ADDRESS 1: Dates Resided From: ________________________ To: ________________________
(Number & Street) (Municipality) (County) (State)
ADDRESS 2: Dates Resided From: ________________________ To: ________________________
Additional forms may be obtained through the New Jersey State Police, Firearms Investigation Unit,
P.O. Box 7068, West Trenton, NJ 08628-0068, or via the internet at www.njsp.org/info/forms.html.
County Adjuster's Office
Institution or Doctor
Signature of Witness
X
* Applicant's Social Security Number is requested pursuant to N.J.S.A. 2C:58-3(e) and disclosure is voluntary. The number will be used to expedite the application.
Without this number, the processing of the application may be delayed. This number is considered confi dential.
