Authorization for the Mutual ROI Between an Outside Group and Acacia Clinics

Overview:

I understand that this document is an authorization for the mutual release of information between an outside group and Acacia Clinics. I understand that I will provide the contact information of the outside group below, and that Acacia Clinics will send this information securely to the outside group directly. I further understand that this document is not an authorization to release my medical record to myself (requires a special release of information).

In authorizing this mutual disclosure, I understand this information will be used solely for the following purposes, now and in the future. Please select one.

Other

What is the name of the outside group?

What is the address of the outside group?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

What is the phone number of the outside group?

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

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.	No, please do NOT release.
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).

Optional: Please add any additional notes for the outside group and 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).

Furthermore, I understand that the information released in response to this authorization may be re-disclosed to other relevant parties (e.g. imaging centers, insurance companies) in the normal course of evaluation, management, and treatment. However, any other disclosure of this information will not be performed by Acacia without my expressed written consent.

Voluntary Nature:

I understand that this authorization is completely voluntary. This consent is subject to revocation in writing at any time. 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 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. However, refusal may lead to operational delays due to additional challenges in retrieving accurate information.

Finally, I understand that I have the right to meet with my clinician to inspect my mental health information record.

Timing:

Finally, I understand that this authorization shall be in force and effect immediately upon submission and until five years 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

Authorization for the Mutual Release of Information between an Outside Group and Acacia Clinics