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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).

1. Who is authorizing the release

Patient Name

Date of Birth

2. Who is releasing the information

Healthcare Provider / Agency releasing the information

3. Who should receive the information

Name of Individual / Agency to Receive the Information

Address / Fax

4. Effective Period

Covers the period of healthcare from

From

All past, present, and future periods.

5. Extent of Authorization

I authorize the release of my complete health record (including records relating to mental health care, communicable disease, HIV/AIDS and treatment of alcohol and drug abuse).

I authorize the release of my complete health record with the following exceptions:

Mental health records

Communicable diseases (including HIV and AIDS)

Alcohol / drug abuse treatment

Other (please 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.

I have read and understand this authorization.

Signature (type full name)

Date