Authorization for the Release of Information to Myself

Overview:

I understand that this document is an authorization for Acacia Clinics to release health information to myself. I understand that I will provide my updated contact information, and that Acacia Clinics will securely send my health information to me.

Timeline & Limitations:

I understand that I may need to meet with my provider. Unless notified by my provider that there is not need to meet, I understand that I will be contacted by Acacia's staff to schedule an appointment. These appointments typically require about 30 minutes. Unless specified by my provider, I also understand that my insurance will be charged the normal fees for a 30-minute doctors visit.

I further understand that medical and mental health records can be very sensitive and that revealing them sometimes comes with substantial risk of significant adverse consequences. I understand that my physician or provider may deny the release of my information in such circumstances. If such a decision is made, I understand that I will be informed and allowed to designate another licensed physician, psychologist, marriage and family therapist, or clinical social worker to receive your records instead.

Otherwise, I understand that upon approval by the physician, that my request would be honored within 15 days of receipt of this form. I understand that if I requested my whole medical record, my provider may choose to provide a detailed summary of the record rather than providing the entire record. This will be done within 10 days of your initial request (this period may be extended to within 30 days from your initial request if your provider notifies you that more time is needed).

Please enter your most up-to-date address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Please enter your most up-to-date phone number.

Please enter a valid phone number.Format: (000) 000-0000.

Please enter your most up-to-date email address.

example@example.com

Please select one of the following options.

I authorize and request the disclosure of just the protected health information that I select below. Please select Yes or No for each row.

Rows	Yes, please release to me.	No, please do NOT release to me.
ALL MEDICAL RECORDS (i.e. meaning every page in my record, including but not limited to: office notes, face sheets, history and physical, consultation notes, inpatient, outpatient and emergency room treatment, all clinical charts, reports, order sheets, progress notes, nurse's notes, social worker records, clinic records, treatment plans, admission records, discharge summaries, requests for and reports of consultations, documents, correspondence, test results, statements, questionnaires/histories, correspondence, photographs, videotapes, telephone messages, and records received by other medical providers).
ALL IMAGING & TARGET RECORDS (e.g. all radiology records and films including CT scan, MRA, EMG,bone scan, myleogram, structural MRI, functional MRI, EEG as well as any previously generated fMRI-derived brain stimulation targets)
ALL MEDICATION RECORDS (e.g. All lists and pharmacy/prescription records including NDC numbers and drug information handouts/monographs.
All LABORATORY REPORTS (i.e. any autopsy, laboratory, histology, cytology, pathology, immuno-histochemistry records and specimens; nerve conduction study, echocardiogram and cardiac catheterization results, videos/CDs/films/reels and reports.
PSYCHOTHERAPY SUMMARY (i.e. Acacia understands that outside groups do not need to disclose any or all psychotherapy notes. However, Acacia may ask for a summary of psychotherapy treatment if not otherwise in the medical records).
BILLING RECORDS (i.e. all billing records and payment records attached to my file).

Optional: Please add any additional notes for Acacia Clinics.

Rights and Cautions

I understand that my medical records, and especially my mental health records, are protected under the California Welfare and Institutions Code (WIC) and the Federal Health Insurance Portability and Accountability Act (HIPAA). I understand that records cannot be disclosed by Acacia without my expressed written consent.

I further understand that I may revoke this authorization at any time from Acacia Clinics. To do so, please contact Acacia Clinics at 877 W Fremont Ave Ste N-3, Sunnyvale, CA 94087. Any use or disclosure made before this revocation of authorization will not be affected. Information disclosed by this authorization may be re-disclosed by recipients and may no longer be protected by the WIC or HIPAA.

Next, I understand that I may refuse to sign this authorization. I understand that my refusal will not affect my ability to obtain treatment or insurance payment or eligibility for benefits.

Finally, I understand that this authorization shall be in force and effect immediately upon submission and until one year from date of execution at which time this authorization expires. I understand that I have a right to receive a copy of this signed authorization.

By signing this electronic authorization form, I agree to its terms and conditions.

My Name

First NameLast Name

My Date of Birth

Date

My Signature

Today's Date

Date