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Home My WebLink Aboutrelease-of-information-fillable-english-lp Alameda County Health Behavioral Health Department (ACBHD) 2000 Embarcadero Cove, Suite 400 Oakland, California 94606 AUTHORIZATION TO DISCLOSE INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION ROI-IIHI. REV 02/2021 PATIENT INFORMATION ID# I HEREBY AUTHORIZE THAT MY INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION BE RELEASED FROM: Alameda County Health Behavioral Health Department (ACBHD) 2000 Embarcadero Cove, Suite 400 Oakland, California 94606 AUTHORIZATION TO DISCLOSE INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION ROI-IIHI. REV 02/2021 I HEREBY AUTHORIZE THAT MY INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION BE RELEASED TO AND USED BY: Physician/Clinic/Hospital/Other Name Alameda County Health Behavioral Health Department (ACBHD) 2000 Embarcadero Cove, Suite 400 Oakland, California 94606 AUTHORIZATION TO DISCLOSE INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION ROI-IIHI. REV 02/2021 INFORMATION REQUESTED For Dates of Service: From: To: Diagnosis  Evaluations    Assessment Discharge  Summary Other: 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.  from: Alameda County Health Behavioral Health Department (ACBHD) 2000 Embarcadero Cove, Suite 400 Oakland, California 94606 AUTHORIZATION TO DISCLOSE INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION ROI-IIHI. REV 02/2021 PURPOSE OF TRANSFER OF RECORDS Permanent Transfer  Referral  Print/Type Name Date REVOCATION: 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. Alameda County Health Behavioral Health Department (ACBHD) 2000 Embarcadero Cove, Suite 400 Oakland, California 94606 AUTHORIZATION TO DISCLOSE INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION ROI-IIHI. REV 02/2021 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