HomeMy WebLinkAboutrelease-of-information-fillable-englishAlameda County Health Behavioral Health Department (ACBHD) 2000
Embarcadero Cove, Suite 400 O a k l a n d, California 94606
AUTHORIZATION TO DISCLOSE INDIVIDUALLY IDENTIFIABLE HEALTH
ROI-IIHI. REV 02/2021
PATIENT INFORMATION
I HEREBY AUTHORIZE THAT MY INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION BE RELEASED
FROM:
Address City/State Zip Code Phone
I HEREBY AUTHORIZE THAT MY INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION BE RELEASED
TO AND USED BY:
Address City/State Zip Code Phone
Alameda County Health Behavioral Health Department (ACBHD) 2000
Embarcadero Cove, Suite 400 O a k l a n d, California 94606
AUTHORIZATION TO DISCLOSE INDIVIDUALLY IDENTIFIABLE HEALTH
ROI-IIHI. REV 02/2021
INFORMATION REQUESTED
For Dates of Service: From: To:
Diagnosis
Evaluations
Psychiatric
Assessment Discharge
I understand that treatment, payment, enrollment, or eligibility for benefits may not be conditioned
on obtaining the authorization and that I am entitled to receive a copy of this authorization and
want and have received such a copy. Y N
EXPIRATION: This Authorization expires twelve (12) months from:
PURPOSE OF TRANSFER OF RECORDS Permanent Transfer Referral
Other:
Signature of Patient Print/Type Name Date
Print/Type Name
REVOCATION: I understand that I have a right to revoke this authorization at any time unless action has
been taken in response to or in reliance on this authorization. I understand that my revocation must be in
writing and presented to an ACBHD Health Information representative in order to revoke the authorization
granted to ACBHD. I further understand that I must present a separate written revocation to any other
person or entity that I have authorized to receive or use my psychotherapy notes above in order to revoke
the authorization granted to that person or entity.
WARNING: PROHIBITIONS ON USAGE, TRANSFER OR REDISCLOSURE OF INFORMATION, except
as required by State or Federal laws, use of information released for other than the stated purpose, or
redisclosure or transfer of this information to any person or entity not named herein is PROHIBITED. An
additional written authorization must be obtained for any proposed new use of the information or for its
redisclosure or transfer of such information. The information disclosed may be subject to redisclosure
and would no longer be protected by federal privacy regulations.
MEDICAL RECORDS WILL BE RETAINED FOR TEN (10) YEARS FOLLOWING A PATIENT’S
DISCHARGE FROM OUR AGENCY, WHEREUPON THEY WILL EITHER BE DESTROYED OR, IF REQUESTED,
DateParent/Guardian