Authorization For Release Of Records And Protected Health Information {FCS-2}

SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN MATEO 400 County Center, 6th Floor Redwood City, CA 94063-1668 Tel. (650) 261-5080 - Fax (650) 261-5142 www.sanmateocourt.org FAMILY COURT SERVICES AUTHORIZATION FOR RELEASE OF RECORDS AND PROTECTED HEALTH INFORMATION Completion of this document authorizes the release of health information and other records as set forth below, consistent with California and Federal law concerning the privacy of such information. Failure to provide all information requested may invalidate this authorization. To: ____________________________________________________________________________________________________ Name: ________________________________________________________ Name: ________________________________________________________ Date of Birth: ___________________________ Date of Birth: ___________________________ I authorize the release of health and other information to Family Court Services from the above person/organization regarding myself and/or my minor children below: Name of Child: ____________________________________ Name of Child: ____________________________________ Name of Child: ____________________________________ Date of Birth: ___________________________ Date of Birth: ___________________________ Date of Birth: ___________________________ This authorization applies to the following health information and other records (select only one of the following): All health information pertaining to any medical history, mental or physical condition and treatment received, including drug/alcohol and/or HIV/AIDS, psychological and/or psychiatric diagnostic evaluation. Only the following records or types of health information (including any dates): ___________________________ This authorization also applies to the following information (select all that applies): Educational Investigative narratives from Child Protective Services I understand that the released records are to be used by the Family Court Services Child Custody Recommending Counselor to assist my family and myself in making recommendations to the Superior Court about the custody and/or visitation of my child(ren). I understand that I am responsible for any fees regarding this request. The records may be released in writing and/or verbally, as requested by Family Court Services. This authorization shall be valid for a one-year period from the date signed, unless consent is withdrawn in writing. RESTRICTIONS California law prohibits the requestor from making further disclosure of my protected health information and other records unless the requestor obtains another authorization from me or unless such disclosure is specifically required or permitted by law. YOUR RIGHTS I may refuse to sign this authorization. I may inspect or obtain a copy of the protected health information and other records that I am being asked to release/disclose. I have a right to receive a copy of this authorization. I may revoke this authorization at any time. My revocation must be in writing, signed by me or on my behalf, and delivered to: Family Court Services, 400 County Center, 6th Fl., Redwood City, CA 94063-1668. My revocation will be effective upon receipt, but will not be effective to the extent that the requestor or others have acted in reliance upon this authorization. Signature: _______________________________________________ Person Authorizing Release Person Authorizing Release _______________________ Relationship Relationship _______________ Date Date Signature: _______________________________________________ A Superior Court hearing ( _______________________ _______________ ) has been set for _____________________________ / ( ) has not been set. We would appreciate having the records/information by _____________________________. If any fees regarding this request should arise, please inform Family Court Services prior to sending the requested information. Print Name: ______________________________ Rev.: 5//2013 Child Custody Recommending Counselor Signature: ______________________________ _______________ Date American LegalNet, Inc. www.FormsWorkFlow.com