AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

(Medical, Mental Health, and Drug and Alcohol Treatment Records)

This authorization pertains to records for the following individual:

Child Parent

Name of Patient

Last / First / Middle
Date of Birth: / Telephone Number
Address:
Other Identifiers:
Court Case Number:

I authorize the entities designated below to disclose the protected health information specified below to the Santa Clara County Department of Family and Children’s Services (DFCS)**. Because this authorization discloses the fact that the patient named above received treatment from each provider designated below, I further authorize all entities designated below to disclose to all other named entities in this authorization the fact that the patient named above received treatment from them.

DURATION: This authorization is valid on the date it is executed and will remain valid until the date designated hereunless it is earlier revoked by me:______(date). The duration may not be valid for more than one year from the date it was executed.

PURPOSE: DFCS will use the requested information to investigate, evaluate, and to coordinate benefits and services and/or use and further disclose it for the purposes described in Welfare and Institutions Code Section 16010.

REVOCATION: I understand that I have a right to revoke this authorization at any time except to the extent that the program or person who is to make the disclosure has already acted in reliance on it. A revocation must be (1) in writing; (2) sent or given to DFCS, or to the treatment provider directly; and (3) is effective when it is received by DFCS or the treatment provider. Once revoked, no further disclosures may be made of your protected health information.

This authorization may be revoked verbally for records relating to drug and alcohol treatment or mental health.

CONDITIONS: I understand that treatment, payment, enrollment, or eligibility for benefits will not be based on my giving or refusing to give this authorization, except if my treatment is related to research, or if health care services are given to me only for creating protected health information for release to a third party. I also understand that I may refuse to sign this authorization.

I understand that I have the right to receive a copy of this authorization form if I request a copy. I also understand that information disclosed pursuant to this authorization could be redisclosed by the recipient. Such redisclosure is in some case not prohibited by California law and may no longer be protected by federal confidentiality law (HIPAA). However, California law prohibits the person receiving my health information from making further disclosures of it unless another authorization for such disclosure is obtained from me or unless such disclosure is required or permitted by law. I expressly authorize the information disclosed pursuant to this authorization to be further disclosed by DFCS for the purposes described in Welfare and Institutions Code Section 16010.

Medical Treatment Providers

I hereby authorize the release of my medical information from:

List Medical Treatment Providers below:

1. Santa Clara Valley Medical Center(751 S. Bascom Ave., San Jose, CA – (408)885-5000) and Valley Health Center Clinics
Medical Record Number:

All diagnosis and treatment records

Other:
2. List Name, Address and Phone Number:
Medical Record Number:

All diagnosis and treatment records

Other:
3. List Name, Address and Phone Number:
Medical Record Number:

All diagnosis and treatment records

Other:

MENTAL HEALTH OR Drug and Alcohol Treatment Providers:

Mental Health or Drug and Alcohol Treatment Records require specific authorization, please initial directly under the listed provider as evidence of your authorization to release the requested records.

(If the minor is 12 years or older and consented to outpatient treatment him or herself or to residential shelter services, only the minor can authorize the release of such records. The signature of the parent or legal guardian is insufficient in these instances.)

I hereby authorize the release of my mental health information from:

List Mental Health Treatment Providers below:

1. Santa Clara County Mental Health Department, 828 S. Bascom Ave., San Jose, CA 95128 and (408)885-5770:
Medical Record Number:

All diagnosis and treatment records

Other:

______(Initial)

2. List Name, Address and Phone Number:
Medical Record Number:

All diagnosis and treatment records

Other:

______(Initial)

I hereby authorize the release of my drug or alcohol abuse treatment information from:

List Drug and Alcohol Treatment Providers below:

1. Santa Clara County Department of Drug & Alcohol Services Adult
System of Care Services:
Medical Record Number:

All diagnosis and treatment records

Other:

______(Initial)

2. List Name, Address and Phone Number:
Medical Record Number:

All diagnosis and treatment records

Other:

______(Initial)

SIGNATURE:
Patient / Representative (circle one) / Date

______

If someone other than the patient is signing this authorization, please complete the following:

Print name of legal representative:
Telephone: / Address:

I am legally authorized to execute this Authorization form on behalf of the individual named above because I am the Parent of Patient Legal Representative of Patient

This authorization form complies with 45 CFR parts 160 and 164, Welfare and Institutions Code Section 5328, 42CRF part 2 and has been approved by the Santa Clara County Office of the County Counsel 9/30/2015

File: 6th Fastener, Right - Middle / SCZ 244
Authorization for Disclosure of Protected Health Information – 7/14/2015
Original to Mental Health Provider / Page 1 of 4