INFORMATION TO BE RELEASED. 1. 1. Copies of chart notes.
INFORMATION TO BE RELEASED. Complete Medical Record Including Billing Statement and Reports Billing Statements Laboratory Reports Dental Records
INFORMATION TO BE RELEASED. This is a full disclosure authorization of health care information which includes health care maintenance records, and medical, surgical, sexually-transmitted disease, mental health, alcohol or other drug abuse care and treatment records, if any. This consent also authorizes the disclosure of HIV test results, if any. These records will be disclosed unless you specify information you wish excluded. Please initial below information you do not want released: NO Exclusions. Exclude: Exclude HIV test results INITIAL INITIAL INITIAL INITIAL Exclude Substance Abuse treatment information Exclude Mental Health treatment information _____ Exclude other information INITIAL This Authorization is effective immediately and will remain in effect for one year or until (date or event) w, hichever comes first. I may revoke this Authorization at any time. My revocation must be in writing, signed by me or on my behalf, and delivered to the address where I received care. My revocation will be effective upon receipt, but will not be effective to the extent that Contra Costa Health Serviceshas acted in reliance upon this Authorization. I have a right to receive a copy of this Authorization. If I am being asked by Contra Costa Health Services to authorize this disclo- sure, I have a right to inspect or obtain a copy of such health information disclosed. I may refuse to sign this Authorization. Neither treatment, payment, enrollment or eligibility for benefits will be conditioned on my providing or refusing to provide this Authorization. This information will be kept confidential as required by Penal Code section 1001.36(h)-(i). Date Patient Signature SIGNATURE OF HOSPITAL STAFF WHEN REQUIRE Signature of Parent, Guardian, etc. Relationship EMPLOYEE NAME DATE D LOCAL COURT FORM (MANDATORY) NEW, EFFECTIVE 11/1/19 MH-005 AUTHORIZATION TO DISCLOSE HEALTH INFORMATION Treatment Participation and Progress Report Attachment 5 Participant’s Name: Progress Period: Docket No. (rpt. period every 30 days) Next Court Date: Treatment Provider: Contra Costa County Superior Court’s Mental Health Diversion Program requires monthly reports of participant’s progress in treatment. A separate form must be completed for every 30 days of treatment. Please reference the treatment plan when you complete the entire form and provide to the participant or his/her attorney of record. Please submit at the end of each month. The last month’s report in the progress period must be submitted at least two days befo...
INFORMATION TO BE RELEASED. (Check all that apply)
INFORMATION TO BE RELEASED. Check one of the following boxes: □ Release all of my record □ Release only the following information: Participant must initial each item to be released Protected health information Public assistance records Vocational rehabilitation assessment or evaluation tools Social security numbers Date of birth Telephone numbers Other (please specify):
INFORMATION TO BE RELEASED. Participant’s job title Job start date Hours worked per week Beginning wage Current employment status Current wage Job end date Benefits available to participant in current job SECTION III – EXPIRATION This authorization expires on: / / Note: A two (2) year expiration date is required in order to receive employment information for follow-up purposes.
