HomeMy WebLinkAboutrelease-of-information-psychotherapy-english-lp Alameda County Health Behavioral
Health Department (ACBHD) 2000
Embarcadero Cove, Suite 400
Oakland, California 94606
AUTHORIZATION TO DISCLOSE
PSYCHOTHERAPY NOTES
PATIENT INFORMATION
I HEREBY AUTHORIZE THAT MY PSYCHOTHERAPY NOTES
BE RELEASED FROM:
Physician/Clinic/Hospital/Other Name
Number
Alameda County Health Behavioral
Health Department (ACBHD) 2000
Embarcadero Cove, Suite 400
Oakland, California 94606
AUTHORIZATION TO DISCLOSE
PSYCHOTHERAPY NOTES
I HEREBY AUTHORIZE THAT MY PSYCHOTHERAPY NOTES
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
PSYCHOTHERAPY NOTES
ROI-P.T.N. REV 02/2021
INFORMATION REQUESTED
For Dates of Service: From: To:
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:
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
Alameda County Health Behavioral
Health Department (ACBHD) 2000
Embarcadero Cove, Suite 400
Oakland, California 94606
AUTHORIZATION TO DISCLOSE
PSYCHOTHERAPY NOTES
ROI-P.T.N. REV 02/2021
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
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
Alameda County Health Behavioral
Health Department (ACBHD) 2000
Embarcadero Cove, Suite 400
Oakland, California 94606
AUTHORIZATION TO DISCLOSE
PSYCHOTHERAPY NOTES
ROI-P.T.N. REV 02/2021
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