Consent For Release And Exchange Of Confidential Health Information {CRM-254}

CONFIDENTIAL SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN DIEGO CENTRAL DIVISION, CENTRAL COURTHOUSE, 1100 UNION ST., SAN DIEGO, CA 92101 CENTRAL DIVISION, COUNTY COURTHOUSE, 220 W. BROADWAY, SAN DIEGO, CA 92101 EAST COUNTY DIVISION, 250 E. MAIN ST., EL CAJON, CA 92020 NORTH COUNTY DIVISION, 325 S. MELROSE DR., VISTA, CA 92081 SOUTH COUNTY DIVISION, 500 3RD AVE., CHULA VISTA, CA 91910 PEOPLE OF THE STATE OF CALIFORNIA DEFENDANT FOR COURT USE ONLY SUPERIOR COURT CASE NUMBER CONSENT FOR RELEASE & EXCHANGE OF CONFIDENTIAL HEALTH INFORMATION (HIPAA) ­ COLLABORATIVE COURT PROGRAMS (CONFIDENTIAL) OTHER IDENTIFYING NUMBER(S) I, , hereby consent to the release and exchange of confidential health information among the _________________________ (collaborative court) team members, including but not limited to the following: __________________________(treatment provider), San Diego Sheriff's Department, San Diego Public Defender's Office, San Diego District Attorney's Office, San Diego City Attorney's Office, San Diego Superior Court, San Diego Police Department or other local police agency, San Diego Probation Department, and Judicial Council of California. The purpose and need for this release is to assist in evaluating and determining appropriate treatment, progress, and compliance with the collaborative court program. Information/Records to be Released Mental Health Evaluation History & Physical Exam Medication Records Laboratory Results Psychiatric Assessment HIV/AIDS Information/Results Client/Service Plan Progress Notes Physician Orders Pharmacy Records Diagnosis Psychological Evaluation Billing Records Alcohol/Drug Treatment Records Nursing Notes Other: ____________________ I understand that the information in my records authorized for release may include information relating to sexually transmitted diseases, Acquired Immunodeficiency Syndrome (AIDS), or infection with the Human Immunodeficiency Virus (HIV). As indicated above, it may also include information about mental health services or treatment for substance abuse. I understand that my alcohol and drug treatment records are protected by the Federal Regulations governing Substance Abuse Patient Records (42 C.F.R., § 2.1 et seq.) and the Health Insurance Portability and Accountability Act ("HIPAA") (45 C.F.R., §§ 160.101 et seq. and 164.102 et seq.) and cannot be released without my specific written authorization, unless the disclosure is otherwise provided for in the above-referenced regulations. I understand that I may inspect or obtain a copy of the information to be used or disclosed, as provided in the Code of Federal Regulations (45 C.F.R., § 164.524). I understand that I have the right to revoke this authorization at any time. If I choose to revoke this authorization, I must do so in writing. Revocation will not apply to information that has already been released based on this authorization. I agree that a photocopy or fax of this authorization for release and exchange of confidential health information will be as effective as the original. This authorization will go into effect on the date of signing and will remain in effect until the collaborative court program termination, completion, or authorization is revoked. I request a copy of this authorization. (Initial here for copy): _________ Date: Date of Birth: Copy given: YES NO Social Security Number: Type or print Participant's full name Signature of Participant SDSC CRM-254 (Rev. 6/17) CONSENT FOR RELEASE AND EXCHANGE OF CONFIDENTIAL HEALTH INFORMATION (HIPAA) ­ COLLABORATIVE COURT PROGRAMS (CONFIDENTIAL) American LegalNet, Inc. www.FormsWorkFlow.com