HomeMy WebLinkAbouttemplate-release-of-information-qa-version-mh-and-sud-v-08-07-24 Karyn Tribble, PsyD, LCSW
Director
Authorization for Release of Confidential Information
(Please fill out both sides of this form)
Consumer’s Last Name First Name Middle Name Date of Birth
Street Address City Zip Code Daytime Telephone
Social Security Number *(Required)
I, request that my protected health information (PHI) from:
Be disclosed to: ACBHD – QA Office
Consumer Assistance
2000 Embarcadero Cove, Suite 400
Oakland, CA 94606
I authorize the following PHI to be released from my medical record(s):
Radiology Reports
Operative Reports
Other:
State and Federal law protect the following information. If this information applies to
you, please indicate if you would like this information released/obtained (include
dates where appropriate):
Mental Health Records
Template_Release of Information QA Version (MH and SUD) v. 08.07.24
2000 Embarcadero Cove, Oakland, CA 94606, Suite 400 | Health.AlamedaCountyCA.gov/ACBHD | 1-510-567-8100 (TTY: 1-510-533-5018)
Yes No
Yes No
Yes No
Yes No
Covering the period of healthcare from: Specific Date(s)_________to________OR All past, present, and future encounters/visits
Purpose for requesting information: Resolving my grievance or appeal request
This consent is subject to revocation by the undersigned at any time except to the
extent that action has been taken in reliance hereon, and if not earlier revoked, it shall
terminate six (6) months from the date of consent. The signer may revoke this release
in writing or by verbally informing Consumer Assistance.
Client or Authorized Representative Signature Date
Print Name Relationship to Patient (if applicable)
Any disclosure of medical records information by the recipient(s) is prohibited except
when implicit in the purpose of the disclosure. PROHIBITION ON RE-DISCLOSURE OF
PROTECTED SUD INFORMATION: 42 CFR Part 2 prohibits unauthorized disclosure of
these records.