HomeMy WebLinkAboutrelease-of-information-psychotherapy-englishAlameda County Health Behavioral Health Department (ACBHD) 2000
Embarcadero Cove, Suite 400 O a k l a n d, California 94606
AUTHORIZATION TO DISCLOSE PSYCHOTHERAPY NOTES
PATIENT INFORMATION
Last Name First Name Middle Initial Date of Birth
Home Phone Work Phone Client ID #
I HEREBY AUTHORIZE THAT MY PSYCHOTHERAPY NOTES BE RELEASED FROM:
Physician/Clinic/Hospital/Other Name
Address City/State Zip Code Phone
Number
I HEREBY AUTHORIZE THAT MY PSYCHOTHERAPY NOTES BE RELEASED TO AND USED BY:
Address City/State Zip Code Phone
Number
Alameda County Health Behavioral Health Department (ACBHD)
2000 Embarcadero Cove, Suite 400 O a k l a n d, California 94606
AUTHORIZATION TO DISCLOSE PSYCHOTHERAPY NOTES
INFORMATION REQUESTED
For Dates of Service: From: To:
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:
Some types of information relating to your mental health treatment are entitled to a higher level
of protection than ordinary mental health or medical records. For these kinds of information,
state and/or federal law require the patient, guardian, or authorized representative to provide a
separate authorization before they may be released to and/or used by others. These include
psychotherapy notes, which are notes taken by treating clinicians about the patient. These notes
may include your statements, summaries of your statements, and/or analyses and conclusions
based on your confidential conversations with your treating clinicians and caseworkers.
By signing, I specifically authorize the release and use of psychotherapy notes in my records.
Signature of Patient Print/Type Name Date
Signature of Parent/Guardian Print/Type Name Date
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,
RETURNED.
ROI-P.T.N. REV 02/2021