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AUTHORIZATION TO RELEASE OR OBTAIN PROTECTED HEALTH INFORMATION
ALAMEDA COUNTY HEALTH CARE FOR THE HOMELESS
1404 Franklin Street, Suite 200, Oakland, CA 94612
TEL (510) 891-8950
www.achch.org
RELEASED FROM:
Alameda County Health Care for the Homeless (510) 891-8950
Name Phone Number Extension
1404 Franklin St., Suite 200, Oakland, CA 94612
Street Address City State Zip Code
I HEREBY AUTHORIZE THAT MY INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION BE
RELEASED TO:
Name (Individual/Organization) Phone Number Extension
(☐) All medical records, including Mental Health and HIV treatment
(☒) Other: 1) ACHCH Medically Frail program eligibility status, and 2) If eligible and matched to
Medically Frail unit, location of unit and required documents needed to complete ACHCH
Medically Frail application.
To limit information to a specific date range, check here (☐) and fill-in the dates below:
For Dates of Service from through
AUTHORIZATION TO RELEASE OR OBTAIN PROTECTED HEALTH INFORMATION
ALAMEDA COUNTY HEALTH CARE FOR THE HOMELESS
1404 Franklin Street, Suite 200, Oakland, CA 94612
TEL (510) 891-8950
www.achch.org
I understand that treatment, payment, enrollment, or eligibility for benefits may not be
conditioned on obtaining this authorization and that I am entitled to receive a copy of this
authorization after I sign it.
EXPIRATION: This Authorization expires twelve (12) months from: (☒) the date signed.
To specify a different expiration, check here (☐) and fill-in the expiration date:______________
PURPOSE OF REQUESTED USE OR DISCLOSURE OF RECORDS/PROTECTED HEALTH
INFORMATION:
(☒)Purpose: 1) Medically Frail Application Assistance/Eligibility Status, and 2) Medically Frail
Unit Placement/Care Coordination
__________________________ _______________________ ___________
Signature of Patient Print/Type Name Date
If required:
__________________________ ________________________ ()Parent __________
Signature of Parent or Guardian Print/Type Name ()Guardian Date
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 Alameda County Health Care for the
(HCH) representative in order to revoke the authorization granted to HCH. 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 individually identifiably health information above in order to
revoke the authorization granted to that person or entity.
WARNING:
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 may no longer be protected by federal privacy
MEDICAL RECORDS WILL BE RETAINED FOR SEVEN (7) YEARS FOLLOWING A PATIENT’S
DISCHARGE FROM OUR AGENCY, WHEREUPON THEY WILL EITHER BE DESTROYED OR, IF
REQUESTED, RETURNED.
S:\Homeless\HCH TRUST CLINIC\ADMINISTRATION AND OPERATIONS\Forms\Consent Forms\Health Info Release REV 12/29/25