State of California HIPAA Release Form and EAP Inquiry From

State of California HIPAA Release Form

AUTHORIZATION FOR THE RELEASE OF PROTECTED HEALTH INFORMATION
All sections must be completed for the authorization to be valid. Use "N/A" if not applicable.
Patient Name*

First NameMiddle NameLast Name
If you are already approved to participate in the EAP, please enter your EAP Subject ID (contact your TB006 provider if you are unsure). If you are not approved, you may leave this field blank.
Date of Birth*

MonthDayYear
Date
Address

Address

Street Address Line 2

City, State, ZIPState / Province

Postal / Zip Code
Part II - Individual/Organization Authorized to Release PHI
Your TB006 Provider's Name*
Address of the clinic

Address

Street Address Line 2

City, State, ZIPState / Province

Postal / Zip Code
Part III - Individual/Organization Authorized by Signatory to Receive PHI
Organization Authorized to Receive Protected Health Information
Part IV - Authorization Expiration Event or Date Unless otherwise revoked by the patient, this authorization for the release of PHI to the above-named individual/organization will expire on the event or date specified below. The default duration is 12 months from the date of the signed signature.

Use "N/A" if not applicable.
Expiration Event
Expiration Date

MonthDayYear
Date
Part V - Health Records to be Released - General
I authorized the following records to be released:*

Medical RecordsDental RecordsOther
If Other, please specify
Part VI - Health Records to be Released - Specific
If you only want to disclose specific health records, please select below:

Communicable DiseasesGenetic TestingHIV ResultsMedication TreatmentMental HealthSubstance Use DisorderPsychotherapy Notes
Note: Requests for psychotherapy notes require a separate authorization and may not be combined with any other request for health records.
Part VII - Purpose for the Release or Use of the Information*

Health CarePersonalLegalOther (please specify below)
Part VIII - Authorization Information

I understand the following:

1. I authorize the use or disclosure of the health information as described abovefor the purpose listed. I understand this authorization is voluntary.

2. I have the right to revoke this authorization. To do so I understand I mustsubmit my revocation in writing to the party entered in Part II. The revocationwill prevent further release of my health information from the date of receipt.

3. I am signing this authorization voluntarily and understand my health caretreatment will not be affected if I do not sign this authorization.

4. The party entered in Part III is prohibited from re-disclosing the healthinformation except with a written authorization or as specifically permitted byCal. Code §56.10 or required by law (applies within California only).

5. If the party entered in Part III is not a HIPAA Covered Entity or BusinessAssociate as defined in 45 CFR §160.103, the released health information may nolonger be protected by federal and state privacy regulations.

6. I have a right to receive a copy of this authorization.

7. Fees may be charged to cover the cost of releasing the health information.

8. I understand that my substance abuse disorder records are protected underthe federal regulations governing the Confidentiality of Substance Use DisorderPatient Records and cannot be redisclosed without my written authorization
Part IX - Signature by or on Behalf of Patient
Name of Patient (Print)*
Patient's Signature*
Authority to sign on behalf of patient (Use NA if patient has signed in the previous box):*
Date*

MonthDayYear
Date
Name of translator (if applicable)
Signature of translator (if applicable)