Please Review the Following and Sign Below:
I understand that only the patient who has consented for care (including minors 13 years of age and older) can authorize for release of records. I understand that these records may contain information relating to psychiatric/mental health, HIV/AIDS, sexually transmitted diseases, and/or drug/alcohol abuse. I give my specific authorization for these records to be released. I understand that authorizing the disclosure of this health information is voluntary. I do no need to sign this form in order to assure treatment or payment. I understand that I can cancel this authorization at any time by writing to South Bay Behavioral Health, 61 Victory Ln, Suite A, Los Gatos, CA 95030. I understand that once the information has been released according to the terms of this authorization, that the information cannot be recalled. I understand that any disclosure of information carries with it the potential for further release or distribution by the recipient that may not be protected by federal confidentiality rules. I may cancel this authorization at any time, except to the extent that action has already been taken. To revoke Authorization to Release Patient Health Information, I must do so in writing. Unless I cancel earlier, this authorization will expire when treatment with South Bay Behavioral Health has ended or one year after date of last visit. Further, I understand that a copy of this document may be faxed or mailed to the above providers.