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Home My WebLink Aboutisa-v3-20200925-final Alameda County Information Sharing Authorization Version 3.0 1 Alameda County Health Care Services Agenc Authorization for Sharing Your Protected Health and Personal Information Client Name: Date of Birth: Medi-Cal CIN (If known): The County of Alameda (the “County”) is asking for your authorization to allow sharing of your protected health information and other personal information (“information”). If you agree, your information will be shared with (to and from) the County and the following types of organizations to help coordinate your care, resources, and human services.  Physical and mental health providers  Social Services Agency  Health plans Housin support  Jail Health Services providers  Crisis response providers  Community services, for example, foodbanks, public libraries, legal services Your information from the types of organizations above will also be shared with Substance Use Disorder (SUD) providers. SUD providers can only receive it to help coordinate your care, resources and human services. Note: This authorization does not allow SUD Providers to share your SUD information. Sharing information makes it easier to see if you are eligible for resources. It also allows you to get services and take part in programs run by the County and other organizations in Alameda County to improve your health (“services” and “programs”). This includes programs and services like Alameda County Care Connect (Care Connect), Healthcare for the Homeless, and Everyone Home. Signing this Authorization Form (“Form”) is your choice. No matter what you choose, it will not change your ability to receive medical services, treatment or public human services. By signing this Form, you are authorizing your information to be shared with (to and from) the County and the types of organizations shown above. It will be used to see if you are eligible for other resources, help link you to them, and help coordinate between them to better serve you. Version 3.0 2 If you do not sign this Form, you can still receive medical services, treatment, or public human services. Not signing may keep you from being able to fully take part in certain programs within the County for coordinating your care. How will sharing benefit me? If you allow your information to be shared, those serving you will be able to:  Identify and connect you to programs, services or resources that could benefit your health and wellbeing.  Better coordinate your care.  Improve the quality of services.  Conduct other program work within the County. How will it be shared? Your information will be shared in electronic formats using a community health record. This is a type of computer program that allows organizations to share information to improve people’s health. Your information will also be shared in verbal and written formats. Who will be sharing my information? Your information will be shared with (to and from) the County and the types of organizations shown above. Your information from the types of organizations above will also be shared with SUD providers. Organizations may include the people who staff County referral or advice call lines. They may also include organizations involved in your care now, in the past and in the future. A list of current organizations will be printed for you. It can also be accessed at www.accareconnect.org/organizations. The person or organization with whom your information has been shared may be able to use or disclose your information without being subject to privacy law. Can I find out who my information is shared with? You have the right to request a list of the organizations that have accessed your information using this Form. To make such a request, call the Alameda County Social Version 3.0 3 Health Information Exchange Help Desk (“Help Desk”) at (510) 618-1997. . What will be shared? Information will be shared about programs and services you got in the past, get now, and in the future. This includes data about:  Physical and mental health conditions.  Housing, human or legal needs. Substance Use Disorder (SUD) information protected by Federal law 42 C.F.R. Part 2 is not included as part of this authorization. Information shared may include details such as:  Your name, address, date of birth, etc.  The status of your medical or mental health, and treatments.  Your housing, food, transportation, employment, income, and disability needs.  The support you get through the County Social Services Agency like Medi-Cal, CalFresh, General Assistance, CALWORKs, Supplemental Security Income. What is still shared if I don’t sign? State and Federal laws already allow for some sharing of information. For example, health care organizations can share your health information to treat you, obtain payment, and run their programs. Signing this Form does not change what can be shared under these laws. Can I limit what gets shared? You may limit sharing of mental health treatment and HIV test results information in the special permission section. If I sign, can I change my mind later? You have the right to change your mind about sharing and revoke this authorization at any time. This Form is valid until the date that you cancel or change it in writing.  To cancel or make a change, talk with your Care Team Member. You can complete a new Form to Version 3.0 4 reflect the change(s). Any changes will take effect as of the date the new Form is signed.  Any data or information shared before that time cannot be recalled. Required Section We need your special permission to share information about mental health treatment and HIV test results. If you give permission, your mental health treatment and HIV test result information will be shared with (to and from) the County and the types of organizations listed above to help coordinate your care, resources, and human services. Even if these do not apply to you today, giving permission can help make sure your information can be shared in the future if needed. Mental health treatment I give permission to share information about my past, present and future mental health treatment. (Psychotherapy notes will not be shared.) □ Yes □ No HIV test results I give permission to share information about my past, present and future HIV test results. □ Yes □ No I have the right to:  Refuse to sign this Form.  Receive a copy of this Form. By signing this Form I agree that:  I have read this Form or an Alameda County Representative or Care Team Member has read it to me.  I understand it.  I give authorization for my information to be shared as described above.  This authorization will remain in effect for a period of 1 year, or until I change or revoke my authorization in writing. I can do this by contacting my Care Team Member. ___________________________________________ ____________________________ Client Signature Date If signed by a person other than the client, please write that person’s relationship to the client: _____________________________________ _____________________________________ Relationship to Client Personal Representative’s Name Version 3.0 5 ---------------------------------------------------------------------------------------------------------------- Revocation of Information Sharing Authorization Client Name: Date of Birth: Medi-Cal CIN (If known): I wish to revoke my authorization. (Please send to your Care Team member) Signature of Client or Client’s Legal Representative: __________________________________________ ________/________/________ Month Day Year If signed by Client’s Legal Representative, state relationship and authority to do so: ____________________________________________________________________