Transcription of AUTHORIZATION FOR RELEASE Confidential Patient …
1 StateofCalifornia-HealthandHumanServices AgencyDepartmentofHealthCareServicesAUTH ORIZATIONFORRELEASEOFPATIENTINFORMATIONC onfidentialPatientInformationSeeW& :Usethisformtoobtaintherequiredauthoriza tionwhenarequestis receivedforpatientinformation,unlessther equestreceivedisafacsimileofthisformor ,obtain witnesssignature. Listtheinformationreleasedper , ,the patientmayinspectorbeprovidedacopyofthep rotectedhealthinformationtobe sNameBirthDateMonthDayYearI, and/orNameofPatientherebyauthorizeNameof Parent/Guardian/ConservatorNameofAgency/ Person/OrganizationAddress(Street,City,S tateandZipCode)toreleasetoNameofAgency/P erson/OrganizationAddress(Street,City,St ateandZipCode)theinformationspecifiedonP age2ofthisformwiththeknowledgethatsuchre lease 1of 3 DHCS 1811 (06/2013)StateofCalifornia-HealthandHuma nServicesAgency DepartmentofHealthCare ServicesAUTHORIZATIONFORRELEASEOFPATIENT INFORMATIONC onfidentialPatientInformationSeeW& *isrequiredforthefollowingpurpose(s).
2 (initialapplicable areas)EvaluationTreatmentPlanning/Course Other(Specify)andshallbelimitedtoreleasi ngthefollowingtypesofinformation(initial allapplicableareas):from(daterequired)to (daterequired);oranyinformation/recordsi ndicated, IndividualTreatment PlanLegalInformationMedical,Assessment, ,EEG,EKG, (specify)NeurologicalLabTests,ResultsofP sychological/ VocationalTesting Conference(s)Date(s)Other(specify)*Thein formationdisclosureunderthisauthorizatio nmaybesubjecttore-disclosurebythe (Month/Day/Year). revoked,itshallterminateattheendof(check one) :SignatureofPatientMonthDayYearDate:Sign atureofParent/Guardian/Conservator,ifApp licableMonthDayYearWitnessSignatureDate: YearDayMonthSignatureofProfessional*Date PersonObtainingAuthorizationDate*Profess ionalforthisauthorizationrefersonlytoaPh ysician,LicensedPsychologistor SocialWorkerwithaMaster sdegreeinsocialwork,orMarriageandFamilyT herapistwho 2of 3 DHCS 1811 (06/2013)StateofCalifornia-HealthandHuma nServicesAgency DepartmentofHealthCare ServicesAUTHORIZATIONFORRELEASEOFPATIENT INFORMATIONC onfidentialPatientInformationSeeW& Identifythespecificdatesofthereports,rec ords, ,Neurological PsychiatricEvaluation Assessment,Lab Tests, ,EEG, DischargeSummary EKG, Assessments(specify)SocialHistoryIndivid ualTreatmentPlanHIVT estsResultsConference(s)Date(s)Resultsof Psychological/ VocationalTestingOther.
3 DateReleasedReleasedBy(Name&Title)Page 3of 3 DHCS 1811 (06/2013)