California Center for Behavioral Health

925 Ygnacio Valley Road, Ste 205, Walnut Creek, CA 94596 · (925) 289-9022 · Fax (888) 965-0556

Release of Information

Authorization for use or disclosure of Protected Health Information (HIPAA 45 C.F.R. Parts 160 and 164).

Please note: This authorization allows CCBH to share or receive your health information with the person or organization you name below. You can revoke this authorization at any time in writing.

1. Patient — Person Authorizing the Release

Patient Name

Date of Birth

2. Provider / Agency Releasing the Information

Provider or Agency

3. Person / Agency Receiving the Information

Name of Recipient

Address & Fax Number

4. Effective Period

From

This authorization covers all past, present, and future periods of care.

5. Extent of Authorization

Release type

Complete record Complete record with exceptions below

If "with exceptions," check what should be excluded:

Mental health records

Communicable diseases (including HIV/AIDS)

Alcohol / drug abuse treatment records

Other (specify below)

Other exclusions — specify

6. Expiration

This authorization expires on

I understand: This information may be used by the person/provider/agency I authorize for medical treatment, consultation, billing, claims payment, or other purposes as I may direct. I have the right to revoke this authorization, in writing, at any time, except to the extent that any person or entity has already acted in reliance on it. My treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization. Information disclosed pursuant to this authorization may be re-disclosed by the recipient and may no longer be protected by federal or state law.

Acknowledgement & Signature

I have read and understand this authorization.

Patient / Guardian Signature (type full name)

Date