California Form AD 22, the Health Facility Minor Release Report, is the one-page report a hospital or other health facility files with the California Department of Social Services (CDSS) whenever it releases a child under 16 to someone who is not a parent, a blood or marriage relative, or a legal custodian. You complete four sections covering the child, the parent’s authorization, the person receiving the child, and the hospital’s own record, then mail the original to CDSS at 744 P Street, M/S 19-67, Sacramento, California 95814 within 48 hours of the child leaving the facility.1California Department of Social Services. Health Facility Minor Release Report
When You Actually Have to File It
Health and Safety Code Section 1283 is the trigger. A health facility cannot release physical custody of a child under 16 without written authorization from a parent, a person with legal custody, or a relative caregiver authorized under Family Code Section 6550. If the person taking the child is anyone else, Form AD 22 is required.2California Legislative Information. California Code Health and Safety Code HSC 1283
Two situations are exempt. The form is not required if the child is simply being transferred to another health facility for continued care. It is also not required if the child falls under Welfare and Institutions Code Section 300, 601, or 602 and is released to an agent of a public welfare, probation, or law enforcement agency.2California Legislative Information. California Code Health and Safety Code HSC 1283 Every other release of a child under 16 to a non-parent, non-relative, non-legal-custodian triggers the report.
In practice, the form shows up in independent adoptions, agency placements, and some foster care transitions.
What to Have in Front of You Before You Start
Chasing information after discharge is the main reason these forms get filed late. Collect all of the following before anyone sits down with the form:
- The child’s full name, birthdate, and sex, taken directly from the Record of Live Birth (VS 10) for a newborn.
- The hospital’s name, address, and license number; the attending physician’s name; and the mother’s admission and discharge dates.
- Both birth parents’ full names, dates of birth, and addresses.
- The receiving party’s name, address, telephone number, and two forms of identification: a driver’s license number with state, plus a Social Security number or other government-issued ID.
The two-ID requirement for the person receiving the child is the detail most often missed. One driver’s license is not enough. Verify both documents when the receiving party arrives, not at the discharge door.
Filling Out the Four Sections
The form is laid out as Sections I through IV, each completed by a different party.
Section I: Child’s Identifying Information
Enter the child’s name, birthdate, and sex. For a newborn, copy the information straight from the VS 10. If the birth certificate has not been finalized, use the hospital’s birth registration worksheet and confirm the entries will match the final document.
Section II: Parent’s Authorization
This is the birth parent’s written consent authorizing the hospital to release the child to a named person or agency. The parent is relinquishing physical custody only; legal custody requires a separate court proceeding. Both birth parents should sign when available.
Section III: Acknowledgement by Person Receiving the Child
The individual taking custody signs here, confirms they are receiving the child, and states the purpose, such as adoption or foster care. Both forms of identification go in this section. If the receiving party is acting on behalf of a licensed adoption agency, record the agency’s name and address alongside the individual’s personal information.1California Department of Social Services. Health Facility Minor Release Report
Section IV: Report of Hospital
This is the facility’s record. Enter the hospital name, address, attending physician, the mother’s admission and discharge dates, and both parents’ names, dates of birth, and addresses. The hospital administrator or a designated representative signs. Double-check the license number and addresses, because CDSS uses this information to contact the parties and errors delay the adoption file.
Where It Goes and Who Keeps a Copy
Prepare the original plus three copies. Distribution is fixed:
- Original: mail to CDSS at 744 P Street, M/S 19-67, Sacramento, California 95814.
- Copy 1: hospital’s permanent administrative and medical file.
- Copy 2: the birth parent.
- Copy 3: the person receiving the child.
The form instructs you to mail the original to the Sacramento address, not to a regional adoption office. The form and the CDSS website give no indication that electronic submission is accepted, so plan on physical mail and build in transit time. For facilities in Southern California, priority or overnight service is a safer bet for meeting the 48-hour window.
The blank form is posted on the CDSS website under the alphabetical “A” listing as “AD 22 (7/02) — Health Facility Minor Release Report — Agency And Independent Adoptions Program.” The second page of the PDF carries the official line-by-line instructions.3California Department of Social Services. On-line Forms and Publications A – D Print all four copies before signatures go on, so every copy carries original ink.
The 48-Hour Clock and What a Late Filing Costs
The deadline runs from the moment the child physically leaves the facility, not from when the paperwork is finalized internally. Treat Form AD 22 as part of the discharge itself.
Violations of the reporting requirements under Health and Safety Code Chapter 2, which includes Section 1283, are misdemeanors. A conviction carries a fine of up to $1,000, up to 180 days in county jail, or both.4California Legislative Information. California Code Health and Safety Code HSC 1290 A pattern of violations can also prompt administrative action against the facility’s license.
When Form AD 22 Is Not Enough
Two situations look like ordinary AD 22 releases but carry extra federal and interstate requirements. The form still gets filed, but it does not stand alone.
If the child is being placed with someone in another state, the Interstate Compact on the Placement of Children (ICPC) requires advance approval from the receiving state before the child crosses state lines. California routes relative-home, foster-family-home, and prospective-adoptive-home requests through counties and licensed adoption agencies; private agency adoptions go through California’s full-service licensed adoption agencies.5California Department of Social Services. Interstate Compact on the Placement of Children (ICPC) The ICPC uses its own forms, notably ICPC-100A, and the receiving state must confirm the placement is not contrary to the child’s interests. AD 22 is filed in addition.
If there is any reason to believe the child may be a member of or eligible for membership in a federally recognized Indian tribe, the Indian Child Welfare Act applies. California’s implementing provisions under Welfare and Institutions Code Section 224.2 require a thorough, documented inquiry with parents, extended family members, and other knowledgeable individuals; a single yes-or-no question is no longer treated as adequate.6Judicial Branch of California. ICWA Inquiry Judicial Best Practices For an “Indian child” under federal law, any consent to adoption given before or within ten days after birth is invalid, and consent must be executed in writing before a judge who certifies the terms were fully explained and understood. If any tribal heritage surfaces at the hospital, flag it to the adoption agency or county welfare department before discharge so the ICWA process can begin.