Santa Cruz — CC packet

Source: https://www.santacruz.courts.ca.gov/system/files/forms-and-filings/cc-packet-april-2025.pdf

Sparse pages use OCR; original PDF remains authoritative.

Collaborative Court Participant Packet (Version April 5, 2025)

This Packet Contains the Following Forms: SUPCR 1131 Collaborate Courts Referral Information Sheet SUPCR 1132 Collaborate Courts Contact and Information SUPCR 1133 Collaborative Courts Release of Information (Substance Use) SUPCR 1134 Collaborative Courts Release of Information (Mental Health) BH 306 Authorization to Release / Share Confidential Information Veterans Release of Information Veterans SF180 Military Records CAFES Release of Information

SUPERIOR COURT OF CALIFORNIA COUNTY OF SANTA CRUZ COLLABORATIVE COURTS OFFICE 701 OCEAN STREET SANTA CRUZ, CA 95060 (831) 420-2498 www.santacruzcourt.org

Collaborative Courts Referral Packet

Mental Health Diversion (MHDA): Mental Health Diversion is based on AB 1810 (PC 1001.35 & PC 1001.36). This legislation gives discretionary diversion of qualified persons who have committed a crime because of mental health disorder. Diversion may be granted during the pretrial stage at any time after the filing of an accusatory pleading.

Eligibility Criteria: Have a recent mental health diagnosis from a Be able to respond to treatment goals. “qualified mental health provider”. Waive the right to a speedy trial. Mental health was a significant factor in the Agree to comply with treatment goals. charged offense. Agree with treatment goals developed by a Not pose “an unreasonable risk of danger treating provider. to public safety” as defined in Section 1170.1, if treated in the community.

Exclusionary Factors: Offence of murder or voluntary manslaughter. Diagnosis of Antisocial Personality Disorder, Any 290 offence except PC 314. Borderline Personality Disorder, or Pedophilia. Offence of PC 11418, weapon of mass destruction.

Once accepted into MHDA, there is an option to place participants into Intensive Support Court (ISC): ISC is a supportive pre-adjudication program aimed at helping individuals facing mental health issues and substance use disorders. It uses a team-based approach to provide integrated support, focusing on mental health diversion and helping participants achieve their treatment goals. Participation in ISC Court is voluntary, and individuals must be willing to engage in the program.

ISC Court has additional eligibility criteria:

Participants should have a significant need for case management, criminal history, and a risk of reoffending.

Form Adopted for MANDATORY USE COLLABORATIVE COURTS REFERRAL Page 1 of 3 Superior Court of Santa Cruz County PACKET INFORMATION SHEET SUPCR 1131 04/03/25

SUPERIOR COURT OF CALIFORNIA COUNTY OF SANTA CRUZ COLLABORATIVE COURTS OFFICE 701 OCEAN STREET SANTA CRUZ, CA 95060 (831) 420-2498 www.santacruzcourt.org

Behavioral Health Court Assessment (BHCA) Behavioral Health Court is a collaborative court that serves individuals who are on formal probation and living with a serious mental health disorder that significantly impairs their daily functioning.

Eligibility Criteria: On formal probation with Santa Cruz County Mental Health Terms. Struggling with a significant and persistent mental health disorder that contributes to substantial functional impairment(s). Eligible for MOST Team Probation supervision or assigned to a specified mental health probation caseload. Eligible for Santa Cruz County Medi-Cal. Amenable to participation in BHC, attend residential treatment programs as recommended, and take medication as prescribed. Veteran Court Assessment (VCA) Veteran Court (VC) mission is to assist justice system-involved veterans and their families with opportunities to improve the quality of life through a collaborative effort among justice system partners, community-based organizations, and county and national veteran’s services. The VC is a peer-support based court program, operating under CA Penal Code § 1170.9 and 1001.80, which provides for alternative sentencing for veterans with service-related mental health issues.

Eligibility Criteria: Amenable to participation in the program and Served in the United States Military, voluntarily agree to all conditions including regardless of length of service, combat treatment for their qualifying condition. experience, or characterization of discharge. (Proof of Military Service can be confirmed by Exclusionary Factors: DD214) No sexual offense (PC § 290), arson (PC § Struggles with a diagnosis of Post-Traumatic 457.1) or gang registrants. Stress Disorder (PTSD), Traumatic Brain Injury No murder or manslaughter (PC § 667.5(c)), (TBI), military sexual trauma (MST), substance current or prior violent felony conviction(s). use, or other mental health symptoms No case where the victim in the current directly related to military service (PC § offense has suffered death or great bodily 1170.9 eligible). injury (permanent disfigurement or permanent disability).

Form Adopted for MANDATORY USE COLLABORATIVE COURTS REFERRAL Page 2 of 3 Superior Court of Santa Cruz County PACKET INFORMATION SHEET SUPCR 1131 04/03/25

SUPERIOR COURT OF CALIFORNIA COUNTY OF SANTA CRUZ COLLABORATIVE COURTS OFFICE 701 OCEAN STREET SANTA CRUZ, CA 95060 (831) 420-2498 www.santacruzcourt.org

Collaborative Courts Referral Process:

Fill out Contact Information Form Client completes and signs all Releases of Information (ROI) Request a Collaborative Court Clinician Assessment (CCCA) from the court for all in-custody clients. If client has any additional mental health records including, out of Santa Cruz County records, please include that documentation with this referral packet. After the packet is received, collaborative courts will contact referral person or attorney for interview and next steps. Upon receiving the packet, collaborative courts will contact the referral person or attorney to arrange an interview and discuss next steps. The court Clinician will follow up with the court after determining eligibility and suitability. A psychological evaluation or clinician screening may be needed for Mental Health Diversion, Veterans Court, or Behavioral Health Court.

Please allow up to one to three weeks to complete the process.

Return referral packet to the collaborative courts box located in the Judge’s Chambers Office or email to collaborativecourt@santacruzcourt.org. If you have questions email collaborativecourt@santacruzcourt.org

Form Adopted for MANDATORY USE COLLABORATIVE COURTS REFERRAL Page 3 of 3 Superior Court of Santa Cruz County PACKET INFORMATION SHEET SUPCR 1131 04/03/25

SUPERIOR COURT OF CALIFORNIA COUNTY OF SANTA CRUZ COLLABORATIVE COURTS OFFICE 701 OCEAN STREET SANTA CRUZ, CA 95060 (831) 420-2498 www.santacruzcourt.org

Collaborative Courts Contact and Information Form

Penal Codes: ☐ 1001.8 ☐ 1170.9 ☐ 1001.36 ☐ 1001.35

Client Name: Date of Referral: DOB: Sex: Phone number: Referral Source Name: Referral Source Phone Number: Case Number(s) Offense(s)

Charge Level: Felony Misdemeanor Primary Care Provider: Violation of Supervision Other Name: Contact number:In Custody: Main Jail Rountree Blaine St. Psychiatrist: R&R Out of Custody Name:Military Service: Yes No Unknown Contact number: If yes, provide SSN Therapist:Military Service Types of Discharge: Name: ☐ Honorable ☐ General ☐ Other than honorable Contact number: ☐ Bad conduct ☐ Dishonorable Mental Health Diagnosis: Enrolled in VA Services: ☐ Yes ☐ No 1) Has been declared PC 1368: Current Past Current Past Documented Self-Report No Unknown 2) Healthcare insurance: Yes No Current Past Documented Self-Report Insurance Provider: County:

Form Adopted for MANDATORY USE COLLABORATIVE COURTS CONTACT Page 1 of 3 Superior Court of Santa Cruz County AND INFORMATION FORM SUPCR 1132 08/30/24

SUPERIOR COURT OF CALIFORNIA COUNTY OF SANTA CRUZ COLLABORATIVE COURTS OFFICE 701 OCEAN STREET SANTA CRUZ, CA 95060 (831) 420-2498 www.santacruzcourt.org

3. Please list all of support services/case
   managers/coordinator/providers/programs you are Current Past Documented Self-Report currently connected with: (TAY, MOST, Emeline,

Psychiatric Medications: HPHP, Housing Matters, CCCIL, Encompass, Front Street, etc.):1) Current Past Documented Self-Report 2) Current Past Documented Self-Report 3) Current Past Documented Self-Report

QUESTIONNAIRE

1. Are you currently employed? 6. Do you struggle with time management and ☐Yes organization? ☐No ☐Yes ☐No ☐Maybe2. Any hospitalizations in the last 12 months?

(Dominican, Telecare, Watsonville Hospital, etc.) 7. How well do you manage your medical ☐Yes appointments? ☐No well well ☐Extremely ☐Somewhat ☐Neutral3. Do you have a permanent physical or mental not well not well ☐Somewhat ☐Extremely disability that limits or impacts your daily living? (i.e., wheelchair, amputation, unable to 8. Drugs and alcohol usage: Do you currently use climb stairs?) any substances or alcohol? Are you in remission? ☐Yes ☐Maybe Are you interested in treatment? ☐No - I am currently using and not ☐No ☐Yes4. How often do you feel angry, sad, stressed, or interested in treatment am in remission depressed? ☐I - I am using and I am interested in ☐Daily ☐Yes ☐Weekly ☐Monthly ☐Seasonal treatment do not want to answer ☐I ☐Yearly ☐Never 9. Do you have a hard time completing tasks?5. Do you need any help getting your prescriptions ☐Yes ☐No ☐Maybe filled and taking your medications? ☐Yes ☐No ☐Maybe

Form Adopted for MANDATORY USE COLLABORATIVE COURTS CONTACT Page 2 of 3 Superior Court of Santa Cruz County AND INFORMATION FORM SUPCR 1132 08/30/24

SUPERIOR COURT OF CALIFORNIA COUNTY OF SANTA CRUZ COLLABORATIVE COURTS OFFICE 701 OCEAN STREET SANTA CRUZ, CA 95060 (831) 420-2498 www.santacruzcourt.org

10. Are you currently able to take care of basic needs 11. Are you familiar with Santa Cruz County available such as bathing, changing clothes, using a resources? (Cal Fresh, Medi-Cal, NAMI, AA/NA, restroom, getting food and clean water and Food pantry, Dientes, Mental Health services, other things like that? ACCESS, etc.) ☐Yes ☐No ☐Maybe ☐Yes ☐No ☐Maybe

By signing below, you acknowledge that you have received information about mental health diversion, you are open to being assessed, and you are interested in receiving mental health services. This includes participating in mental health programming as recommended, taking all medication as prescribed, abstaining from all substances, submit to testing and follow directives of mental health provider.

Participant Signature Date

Form Adopted for MANDATORY USE COLLABORATIVE COURTS CONTACT Page 3 of 3 Superior Court of Santa Cruz County AND INFORMATION FORM SUPCR 1132 08/30/24

SUPCR 1133 SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CRUZ

SANTA CRUZ BRANCH WATSONVILLE BRANCH
701 Ocean Street, Room 120 1 Second Street, Room 300
Santa Cruz, CA 95060 Watsonville, CA 95076

Authorization for Use, Exchange, and/or Discharge of Confidential Substance Use Disorder
Information for entry and participation in the Collaborative Courts

I , (print name of client or client’s representative) (print date of birth) hereby authorize the Superior Court of Santa Cruz Collaborative Courts, to disclose Mental Health information, Health information, Substance Use treatment history, HIV test results and status, Written Assessments Other (specify): to: Santa Cruz County Department of Probation: (Name) Santa Cruz County District Attorney Representative: (Name) Santa Cruz County Public Defender Representative: (Name) Department of Veterans Affairs: (Name) Santa Cruz County Health Services Agency: (Name) Santa Cruz County Sheriff’s Department: (Name) California Department of Corrections and Rehabilitation: (Name) Goodwill of Central Coast (Name) Other:

Form Adopted for MANDATORY USE COLLABORATIVE COURTS ROI Page 1 of 2 Superior Court of Santa Cruz County SUBSTANCE USE DISORDERSUPCR 1133 01/01/22

Purpose of disclosure: To help assess and determine appropriate treatment, progress, and compliance with the Collaborative Courts. Consent: Without my express cancellation or change, this consent remains in effect until my participation in Collaborative Court is terminated or completed. “Termination” is when my participation in Collaborative Court ends before I finish the program. “Completion” is when I successfully complete participation in Collaborative Court. I may cancel or change this authorization at any time by submitting a written request to the Superior Court of Santa Cruz County. A cancellation or change goes into effect once the written request is received by the Superior Court of Santa Cruz County. I have a right to refuse to sign this authorization. The Superior Court of Santa Cruz, Collaborative Courts, may refuse to conduct an assessment if I do not authorize the release of medical and mental health information to the Collaborative Court team. I have a right to a copy of this authorization. A recipient of medical information pursuantto this authorization may not further disclose the medical information except in accordance with a new authorization that meets the requirements of California Health and Safety Code section 56.11, or as specifically required or permitted by law.

Signature: Date:

If signed by someone other than the client, state your legal relationship:

Witness: Date:

Form Adopted for MANDATORY USE COLLABORATIVE COURTS ROI Page 2 of 2 Superior Court of Santa Cruz County SUBSTANCE USE DISORDERSUPCR 1133 01/01/22

SUPCR 1134 SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CRUZ

SANTA CRUZ BRANCH WATSONVILLE BRANCH
701 Ocean Street, Room 120 1 Second Street, Room 300
Santa Cruz, CA 95060 Watsonville, CA 95076

Authorization for Use, Exchange, and/or Discharge of Confidential Mental Health and Medical Information for entry and participation in the Collaborative Courts

I , (print name of client or client’s representative) (print date of birth) hereby authorize the Superior Court of Santa Cruz Collaborative Courts, to disclose Mental Health information, Health information, Substance Use treatment history, HIV test results and status, Written Assessments Other (specify): to:

Santa Cruz County Department of Probation: (Name) Santa Cruz County District Attorney Representative: (Name) Santa Cruz County Public Defender Representative: (Name) Department of Veterans Affairs: (Name) Santa Cruz County Health Services Agency: (Name) Santa Cruz County Sheriff’s Department: (Name) California Department of Corrections and Rehabilitation: (Name) Goodwill of Central Coast: (Name) Other:

Form Adopted for MANDATORY USE COLLABORATIVE COURTS ROI Page 1 of 2 Superior Court of Santa Cruz County MENTAL HEALTH AND MEDICALSUPCR 1134 05/11/23

Purpose of disclosure: To help assess and determine appropriate treatment, progress, and compliance with the Collaborative Courts. Consent: Without my express cancellation or change, this consent remains in effect until my participation in Collaborative Court is terminated or completed. “Termination” is when my participation in Collaborative Court ends before I finish the program. “Completion” is when I successfully complete participation in Collaborative Court. I may cancel or change this authorization at any time by submitting a written request to the Superior Court of Santa Cruz County. A cancellation or change goes into effect once the written request is received by the Superior Court of Santa Cruz County. I have a right to refuse to sign this authorization. The Superior Court of Santa Cruz, Collaborative Courts, may refuse to conduct an assessment if I do not authorize the release of medical and mental health information to the Collaborative Court team. I have a right to a copy of this authorization. Substance use disorder records are protected under the federal regulations governing Confidentiality of Substance Use Disorder Patient Records, 42 C.F.R. Part 2, and cannot be disclosed without my written consent unless otherwise provided for in the regulations.

Signature: Date:

If signed by someone other than the client, state your legal relationship:

Witness: Date:

Form Adopted for MANDATORY USE COLLABORATIVE COURTS ROI Page 2 of 2 Superior Court of Santa Cruz County MENTAL HEALTH AND MEDICAL SUPCR 1134 05/11/23

1 1400 Emeline Avenue, 1430 Freedom Blvd. Ste F, Santa Cruz, CA 95060 Watsonville, CA 95076 Phone: (831) 454-4170 Phone: (831) 454-4170 Fax: (831) 454-4663 Fax: (831) 454-4663 Client Legal Name: Avatar No: Nickname/Alias: Date of Birth: Phone: Address: City: State: Zip: 2 AUTHORIZATION for the RELEASE/SHARE of CONFIDENTIAL INFORMATION I, ____________________________________________(PRINT NAME of LEGAL AUTHORIZOR) authorize Behavioral Health Services _ MHP or SUDS (check appropriate box) Staff to share (give and/or receive) the below identified information to: (AGENCY/ENTITY) authorized to receive my treatment information. [CARES Act permits “organization/agency” for SUD disclosures.] Recipient Name: __________________________________________________________________ Address: _____________________________________________ Phone: ______________________ [FOR Children’s Mental Health (CBH) staff (minor ownership): My signature below confirms that I have assessed this 12-17 year old minor and determined the minor does does not have the capacity to authorize the release of her/their/his protected health information.] _________________/ (CBH Staff Signature/Date) 3 The purpose for the communication, disclosure and exchange of this information is: X Facilitate treatment/payment/operational coordination Summarize treatment Other (Specify reason): _________________________________________________________________________ Claims Assistance Quality of Care Review/Complaint Appointment Support/Scheduling Help 4 I permit staff to release/share the following sensitive information: [please check appropriate boxes]: x All Mental Health Treatment Information: FROM _________ TO _________ [Optional: Specify Unique Date Limit] All Substance Use Disorder Treatment Information: FROM __________ TO __________ [REQUIRED for SUD: Specify Unique Date Range Limits – 42 CFR section 2.31] Only the following information (can specify any type and/or date range): _______________________

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Diagnosis Only treatment enrollment confirmation Psychiatry treatment, including medications

HIV/AIDS Test Results (A separate authorization is required for each disclosure & required signer initials): ____ 5 DURATION: This authorization is valid until: _________________________ (Date or event) or one (1) year from the date this form is signed, whichever date is earlier. 6 MY RIGHTS: (1) I may refuse to sign this Authorization. My refusal will not affect my ability to obtain treatment or eligibility for benefits.(2) I understand that this is a communication release.3) I understand if I authorize disclosure of my protected health information to someone who is not covered by confidentiality laws (such as a family friend) it is possible that my information may be re-disclosed by that person to someone else.(4) I may revoke this authorization at any time by submitting a written revocation to: Quality Improvement, 1400 Emeline Avenue, Santa Cruz, CA 95060 to activate the revocation effective date.(5) I have the right to a copy of this authorization form and was offered a copy.(Initial: ___) 7 Client Signature: Date:

8 Parent/Legal Guardian Signature: ____________________________________________ Date: _________________ (If signed by someone other than the client, state your legal relationship to the client): __________________________ Behavioral Health Staff (Print/Sign): __________________________________________________Date: ___________ Legal Guardian or Conservator must provide a copy of current legal appointment papers to receive information

BH 306 Authorization to Release/Share Confidential Information [Rev 11/17/2020-CL]

Release of Information Form Instructions

1 • Please fill out client information in Box 1 • Behavioral Health Staff can help with the Avatar Number

2 • Client to enter name on the first line • Client to mark the type of Behavioral Health Services provider who is authorized to release or share treatment information: Choose: “MHP” box for mental health treatment provider or “SUDS” box for substance use disorder treatment provider. Both boxes can not be selected. • Recipient Name: Client to enter person’s name or entity/organization and fill in address and phone number of entity who can receive treatment information. o If Client wants SUD staff to share information with MH staff, Enter “Behavioral Health Services” • If Client receiving mental health services is a minor 12 years of age or older and wants to release information, then Children’s Mental Health (CBH) staff box needs completion before form is valid.

3 • Check any box(s) that describes the reason for the exchange or disclosure of this information

4 • Check any box(s) that describes what type of information you are permitting staff to release or share. • Note that for Mental Health treatment entering a “From” and “To” Date is optional • Note that for Substance Use Disorder treatment information “From” and “To” date is required • Note that for HIV / AIDS Test Results to be released you must initial the form and a separate authorization is required for each HIV / AIDS disclosure

5 • Indicate how long the authorization is valid • This release is valid beginning immediately when you sign the form • You can indicate an end date that is any time up to one (1) calendar year (12 months) from the date you sign the form • If no end date is entered, the release will expire 12 months from the date the form is signed

6 • Your RIGHTS – Please read! • You have a right to have a copy of this authorization. Please initial that you have been offered a copy

7 • Sign and date the release of information

8 • If you are not the client, describe your relationship to the client and legal authority to sign the form • You may be required to provide legal paperwork • Behavioral Health staff may sign the form as a staff witness

BH 306 English Instructions [Revised 11/17/2020]

BH 306 Authorization to Release/Share Confidential Information [Rev 11/17/2020-CL]

Client Name: ______________________________ Client #_______________ SUDS

Santa Cruz Office Watsonville Office
1400 Emeline Avenue 1430 Freedom Blvd. Suite F
Santa Cruz, CA 95060 Watsonville, CA 95076
Phone: (831) 454-4170 Phone: (831) 763-8200
Fax: (831) 454-4663 Fax: (831) 763-8231

SUBSTANCE USE SERVICES CONSENT FOR ELECTRONIC HEALTH RECORD EXCHANGE County of Santa Cruz Behavioral Health Services, and Network Providers utilize a secure, shared Electronic Health Record (EHR) system called Avatar to store your Protected Health Information (PHI). PHI that is stored in the shared EHR system includes but is not limited to your personal identifying information, payment information, assessments, treatment plans, progress notes, medications, and drug testing results. Having your PHI stored in the shared EHR system provides many benefits to you by allowing your care providers faster access to your health records and enabling them to better coordinate your care to ensure the best possible treatment for you. In the event of an emergency or disaster, consenting to allow your treatment providers to access your PHI in the shared EHR allows your care providers to give you faster, more effective, timely treatment when it matters most. County of Santa Cruz Behavioral Health Services and Network Providers are committed to upholding the confidentiality of all EHR stored in Avatar in accordance with both federal and State privacy regulations including Health Insurance Portability and Accountability Act (HIPAA), 42 CFR Part 2 and the CARES Act. Only providers directly involved with your care have authorization to access your EHR for the purposes of treatment, payment, or healthcare operations. Current List of Avatar Providers County of Santa Cruz Mental Health Treating Providers ● County of Santa Cruz SUD Treating Providers Encompass Mental Health Treating Providers ● Encompass Community Recovery SUD Treating Providers ● Janus of Santa Cruz SUD Treating Providers ● Sobriety Works SUD Treating Providers● New Life Community Center SUD Treating providers ● Volunteer Center Mental Health Treating Providers ● Front Street Mental Health Treating Providers ● Pajaro Valley Prevention & Student Assistance Mental Health Treating Providers ● Pajaro Valley Prevention & Student Assistance SUD Prevention Treating Providers ● Haven of Hope Mental Health Treating Providers ● Parent Center Mental Health Treating Providers ● Telecare Crisis Stabilization Program ● Horizon Service Providers

How Is My Privacy Protected?

County of Santa Cruz Behavioral Health Services and participating Network Providers use a combination of safeguards to protect your PHI. Technical safeguards include encryption, password protection and the ability to track every viewer’s usage of the system. All participating providers must agree to follow written policies controlling access to information through the shared EHR system. Participating providers must follow federal 42 CFR Part 2, CARES Act and HIPAA regulations; in addition to federal and State privacy laws. Please reference our Notice of Privacy Practices that was provided to you for more information.

Your Consent Rights You have the right to either give or deny consent to have your PHI exchanged with participating network providers in the shared EHR system. If you deny consent, to exchange your PHI over the shared EHR system, it will not affect your ability to obtain treatment or your eligibility for benefits. When you deny consent, your EHR will be “sequestered”, meaning your PHI will be stored in the EHR system but will only be viewable to the agency where you currently receive services. With the exception of your first and last name, your EHR would not be searchable to anyone else in the network. When “sequestered” your treatment providers from different programs will not be able to view or share information with each other over the shared EHR system. Having your EHR sequestered will impact your providers ability to get access to the most relevant treatment information about you, which would impact their ability to coordinate your services in a timely manner and provide you with the best quality of care. If you give consent for your PHI to be exchanged over the shared EHR, you have the right to revoke your consent at any time. This revocation must be in writing. You also have a right to request, in writing, a list of entities to whom your information has been disclosed within the last two years. The County must respond within 30 days to this written request. You have a right to receive a copy of this consent form. If you have any questions or concerns about how your information will be stored, used, or accessed through the shared EHR system you may contact the Quality Improvement at 1-800-952-2335. Submit all written requests to: Quality Improvement, 1400 Emeline Ave. 2nd Floor, Santa Cruz, CA 95060

Your Consent Choices (initial only one): _____ I GIVE CONSENT for all authorized providers who are part of my treatment team within County of Santa Cruz Behavioral Health Services and included Network Providers to exchange my (PHI) through the shared EHR system for the purposes of treatment, payment or healthcare operations in accordance with HIPAA, 42 CFR Part 2 and the CARES Act regulations. _____ I DENY CONSENT for the County of Santa Cruz Behavioral Health Services and included Network Providers to exchange my (PHI) through the shared EHR system for any reason unless the law specifically permits it without my consent. I understand that my information will still be stored on the shared EHR system but will be sequestered and not accessible to any of the other network providers except for my first and last name. DURATION: This consent is valid until the end of treatment unless it is revoked in writing.

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Client Signature Date Client Printed Name Date

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Parent/Legal Guardian Signature or Authorized Representative Date

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Printed Name (Parent/Legal Guardian or Authorized Representative) Date

BHSUDS 307 Page 2 of 2 Rev. 10/16/2020

‘County of Santa Cruz HEALTH SERVICES AGENCY POST OFFICE BOX 962, 1080 EMELINE AVENUE, SANTA cRuz, CA 95061-0962 SANTA CRUZ HEALTH CENTER WATSONVILLE HEALTH CENTER 1080 EMELINE AVE. 1430 FREEDOM BLVD. SANTA CRUZ, CA 95060 WATSONVILLE, CA 95076 (831) 454-4100 FAX (831) 454-4296 . (831) 763-8400 FAX (831) 763-8237 TDD: (831) 454-4123 OUTPATIENT MEDICAL CLINICS DIVISION AUTHORIZATION TO RELEASE INFORMATION FROM MEDICAL RECORDS Hereby authorize To furnish to (name and address of person or organization) ; (name and address of person or organization) any and all records obtained in the course of my diagnosis and treatment, which pertain to and may include the mention of alcohol and/or drug abuse, psychiatric illness, HIV+, AIDS Related Complex (ARC), and/or Acquired Immune Deficiency Syndrome (AIDS), conceming: ae (patient's name) ; (patient's social security number) (patient's date of birth) (patient's medical record number) The disclosure of records is required for the following purposes: The disclosure shall be lintited to the following specific types of information: This consent shall expire: (date)

| understand | have a right to receive a copy of this authorization upon my request.

Copy requested and received: Yes No__—_—sInitials A copy of this consent is just as valid as an original. Patient signature : (date) Witness name and title . Parent, guardian or authorized representative of patient PROHIBITION ON REDISCLOSURE: This information is being disclosed to you from records which confidentiality is protected by federal law. Federal regulations (42CFR part 2) prohibit you from making any further disclosure of this information except with a specific written consent of the person to whom it pertains. HSA 220-SP (rev 02/08/17)

County of Santa Cruz HEALTH SERVICES AGENCY POST OFFICE BOX 962, 1080 EMELINE AVENUE, SANTA CRUZ, CA 95061-0962 SANTA CRUZ HEALTH CENTER WATSONVILLE HEALTH CENTER 1080 EMELINE AVE. 1430 FREEDOM BLVD. SANTA CRUZ, CA 95060 ; WATSONVILLE, CA 95076 (831) 454-4100 FAX (831) 454-4296 (831) 763-8400 FAX (831) 763-8237 TDD: (831) 454-4123 DIVISION MEDICA AMBULATORIA Autorizacién para liberar informacién de su historia médica Yo, por la presente autorizo el suministro a (nombre y direccién de la persona u organizacién) (nombre y direccién dela pérsona u organizacién) cualquiera y toda informacién médica obtenida durante el curso de mi tratamiento y diagnéstico, los cuales tengan alguna pertinencia a, y puedan incluir la mencién de abuso, de alcohol y/o de drogas, enfermedad psiquidtrica, HIV+, el complejo relacionado al SIDA (ARC), y/o Sindrome de Inmune Deficiencia Adquirida (SIDA), referente a: 4 (Nombre del paciente). (Numero de seguridad social del paciente) (fecha de nacimiento) (Numero dé historia medico del paciente) Esta revelacién de informacion médica es necesaria pata los siguientes propésitos: Esta revelacién de datos estara limitada a los siguientes tipos de informacién especifica: Este consentimiento se vencera: (fecha) : Si la solicito, entiendo que tengo el derecho de recibir una copia de esta autorizacion. Copia solicitada y recibida: Si No_ lniciales Una copia de esta planilla de consentimiento es tan valido como la original. Firma del paciente (fecha) Testigo (nombre y titulo) Padre, guardian o representante autorizado del paciente , PROHIBICION DE SU RE-REVELACION: Esta informacién se le esta siendo revelada de una fuente de datos que esta confidencialmente protegida bajo la ley federal. La regulacién federal (42CFR parte 2) le prohibe hacer revelacion ° adicional de esta informacién, sin tener el consentimiento por escrito de la persdna de la ‘cual se trata. . HSA 220-SP (rev 02/08/17)

COUNTY OF SANTA CRUZ Human Services Department AUTHORIZATION FOR RELEASE OF INFORMATION AUTHORIZED REPRESENTATIVE Case Name: Case Number: Worker Name: Phone Service Center Worker Number: BCCW Worker Telephone: (888) 421-8080 Date: Welfare and Institutions Code 10850.2 provides, in part, that ...records...of 5 1 5 1 1 11 1076 571 44 21 97.012901 any 5 1 5 1 1 12 1131 566 72 27 96.945564 public 5 1 5 1 1 13 1214 565 128 22 96.406723 assistance 5 1 5 1 1 14 1354 571 115 22 96.209869 programs 5 1 5 1 1 15 1481 566 54 22 96.220230 shall 5 1 5 1 1 16 1548 566 28 22 96.220230 be 4 1 5 1 2 0 119 611 1456 30 -1 5 1 5 1 2 1 119 617 60 20 96.762329 open 5 1 5 1 2 2 190 611 34 21 96.972069 for 5 1 5 1 2 3 234 611 121 27 96.561394 inspection 5 1 5 1 2 4 367 612 28 26 96.689552 by 5 1 5 1 2 5 405 612 38 21 96.971336 the 5 1 5 1 2 6 454 612 104 26 96.932007 recipient 5 1 5 1 2 7 568 613 23 21 96.923828 to 5 1 5 1 2 8 601 612 70 21 96.923828 which 5 1 5 1 2 9 681 612 38 21 96.874153 the 5 1 5 1 2 10 730 612 137 22 96.572716 information 5 1 5 1 2 11 879 613 88 25 96.572716 relates, 5 1 5 1 2 12 979 613 44 21 97.007782 and 5 1 5 1 2 13 1035 613 28 27 97.018097 by 5 1 5 1 2 14 1073 618 45 22 97.016602 any 5 1 5 1 2 15 1129 619 81 21 96.816261 person 5 1 5 1 2 16 1221 613 127 22 96.955940 authorized 5 1 5 1 2 17 1360 613 20 22 96.940704 in 5 1 5 1 2 18 1390 613 80 27 96.952362 writing 5 1 5 1 2 19 1481 614 28 27 97.009155 by 5 1 5 1 2 20 1520 614 55 21 97.009155 such 4 1 5 1 3 0 119 659 1457 30 -1 5 1 5 1 3 1 119 659 111 27 96.455971 recipient. 5 1 5 1 3 2 256 659 49 22 96.803703 The 5 1 5 1 3 3 317 659 90 22 96.453255 written 5 1 5 1 3 4 421 659 173 22 96.852005 authorization 5 1 5 1 3 5 609 660 63 21 96.024475 shall 5 1 5 1 3 6 685 660 31 21 96.024475 be 5 1 5 1 3 7 729 660 73 22 96.246109 dated 5 1 5 1 3 8 816 660 47 22 96.862091 and 5 1 5 1 3 9 877 660 88 27 96.788620 signed 5 1 5 1 3 10 980 661 30 26 96.719803 by 5 1 5 1 3 11 1024 661 62 21 96.719803 such 5 1 5 1 3 12 1100 661 116 27 95.927956 recipient 5 1 5 1 3 13 1229 661 48 21 96.902687 and 5 1 5 1 3 14 1290 661 62 22 96.719681 shall 5 1 5 1 3 15 1366 661 79 27 96.669800 expire 5 1 5 1 3 16 1458 667 50 16 96.971687 one 5 1 5 1 3 17 1520 667 56 22 96.730377 year 2 1 6 0 0 0 117 708 369 22 -1 3 1 6 1 0 0 117 708 369 22 -1 4 1 6 1 1 0 117 708 369 22 -1 5 1 6 1 1 1 117 708 61 21 95.959488 from 5 1 6 1 1 2 187 708 41 21 95.959488 the 5 1 6 1 1 3 238 708 55 22 96.466827 date 5 1 6 1 1 4 302 708 27 22 96.466827 of 5 1 6 1 1 5 336 708 150 22 96.011330 execution.” 2 1 7 0 0 0 1587 532 10 240 -1 3 1 7 1 0 0 1587 532 10 240 -1 4 1 7 1 1 0 1587 532 10 240 -1 5 1 7 1 1 1 1587 532 10 240 95.000000 2 1 8 0 0 0 98 529 9 240 -1 3 1 8 1 0 0 98 529 9 240 -1 4 1 8 1 1 0 98 529 9 240 -1 5 1 8 1 1 1 98 529 9 240 95.000000 2 1 9 0 0 0 99 747 1492 41 -1 3 1 9 1 0 0 99 747 1492 41 -1 4 1 9 1 1 0 99 747 1492 41 -1 5 1 9 1 1 1 99 747 1492 41 95.000000 2 1 10 0 0 0 91 834 1266 54 -1 3 1 10 1 0 0 91 834 1266 54 -1 4 1 10 1 1 0 91 834 835 28 -1 5 1 10 1 1 1 91 834 94 25 3.979521 i 5 1 10 1 1 2 785 852 3 8 90.327896 , 5 1 10 1 1 3 799 835 95 27 96.821785 residing 5 1 10 1 1 4 903 837 23 21 96.564217 at 4 1 10 1 2 0 311 868 1046 20 -1 5 1 10 1 2 1 311 868 205 19 86.838005 APPLICANT/CLIENT 5 1 10 1 2 2 523 869 63 18 96.491684 NAME 5 1 10 1 2 3 1159 870 86 18 96.699135 STREET 5 1 10 1 2 4 1251 869 106 19 95.757523 ADDRESS 2 1 11 0 0 0 937 851 641 21 -1 3 1 11 1 0 0 937 851 641 21 -1 4 1 11 1 1 0 937 851 641 21 -1 5 1 11 1 1 1 937 851 641 21 95.000000 2 1 12 0 0 0 116 851 667 20 -1 3 1 12 1 0 0 116 851 667 20 -1 4 1 12 1 1 0 116 851 667 20 -1 5 1 12 1 1 1 116 851 667 20 95.000000 2 1 13 0 0 0 783 927 738 29 -1 3 1 13 1 0 0 783 927 738 29 -1 4 1 13 1 1 0 783 927 738 29 -1 5 1 13 1 1 1 783 945 4 8 82.576767 , 5 1 13 1 1 2 798 927 29 23 96.368279 do 5 1 13 1 1 3 836 927 83 28 96.368279 hereby 5 1 13 1 1 4 928 927 113 23 96.173813 authorize 5 1 13 1 1 5 1049 927 38 23 96.771072 the 5 1 13 1 1 6 1097 927 114 29 96.821442 person(s) 5 1 13 1 1 7 1220 927 63 23 96.964149 listed 5 1 13 1 1 8 1293 927 71 23 96.636269 below 5 1 13 1 1 9 1371 929 22 21 96.961624 to 5 1 13 1 1 10 1402 929 36 21 96.955826 act 5 1 13 1 1 11 1447 933 28 17 96.445305 as 5 1 13 1 1 12 1484 933 37 23 96.968597 my 2 1 14 0 0 0 88 943 694 21 -1 3 1 14 1 0 0 88 943 694 21 -1 4 1 14 1 1 0 88 943 694 21 -1 5 1 14 1 1 1 88 943 694 21 95.000000 2 1 15 0 0 0 329 961 236 18 -1 3 1 15 1 0 0 329 961 236 18 -1 4 1 15 1 1 0 329 961 236 18 -1 5 1 15 1 1 1 329 961 166 18 96.263725 CITY/STATE/ZIP 5 1 15 1 1 2 502 962 63 17 96.639160 CODE 2 1 16 0 0 0 88 1030 1400 26 -1 3 1 16 1 0 0 88 1030 1400 26 -1 4 1 16 1 1 0 88 1030 1400 26 -1 5 1 16 1 1 1 88 1030 174 25 96.568069 representative 5 1 16 1 1 2 271 1030 21 20 96.568069 in 5 1 16 1 1 3 301 1030 38 21 96.863701 the 5 1 16 1 1 4 348 1031 91 20 96.844185 matters 5 1 16 1 1 5 448 1030 115 26 95.929443 regarding 5 1 16 1 1 6 573 1036 37 20 96.885216 my 5 1 16 1 1 7 618 1035 64 16 96.606628 case. 5 1 16 1 1 8 700 1030 47 21 96.456833 You 5 1 16 1 1 9 757 1035 39 16 96.456833 are 5 1 16 1 1 10 805 1030 83 26 96.834679 hereby 5 1 16 1 1 11 896 1030 128 21 96.653793 authorized 5 1 16 1 1 12 1033 1031 23 20 96.486603 to 5 1 16 1 1 13 1065 1030 89 21 96.818832 release 5 1 16 1 1 14 1163 1030 44 21 96.612587 and 5 1 16 1 1 15 1216 1030 91 21 96.831398 discuss 5 1 16 1 1 16 1315 1030 26 22 96.168922 all 5 1 16 1 1 17 1352 1030 136 22 96.371567 information 2 1 17 0 0 0 87 1100 751 27 -1 3 1 17 1 0 0 87 1100 751 27 -1 4 1 17 1 1 0 87 1100 751 27 -1 5 1 17 1 1 1 87 1100 115 26 96.480225 regarding 5 1 17 1 1 2 212 1105 36 22 96.895569 my 5 1 17 1 1 3 726 1100 112 27 95.453651 eligibility. 2 1 18 0 0 0 260 1119 458 16 -1 3 1 18 1 0 0 260 1119 458 16 -1 4 1 18 1 1 0 260 1119 458 16 -1 5 1 18 1 1 1 260 1119 458 16 95.000000 2 1 19 0 0 0 91 1269 390 28 -1 3 1 19 1 0 0 91 1269 390 28 -1 4 1 19 1 1 0 91 1269 390 28 -1 5 1 19 1 1 1 91 1270 36 26 96

1 1 1 87 1100 115 26 96.480225 regarding

5 1 17 1 1 2 212 1105 36 22 96.895569 my 5 1 17 1 1 3 726 1100 112 27 95.453651 eligibility. 2 1 18 0 0 0 260 1119 458 16 -1 3 1 18 1 0 0 260 1119 458 16 -1 4 1 18 1 1 0 260 1119 458 16 -1 5 1 18 1 1 1 260 1119 458 16 95.000000 2 1 19 0 0 0 91 1269 390 28 -1 3 1 19 1 0 0 91 1269 390 28 -1 4 1 19 1 1 0 91 1269 390 28 -1 5 1 19 1 1 1 91 1270 36 26 96.739609 My 5 1 19 1 1 2 136 1269 126 22 96.453453 authorized 5 1 19 1 1 3 272 1270 175 27 96.883308 representative 5 1 19 1 1 4 456 1269 25 22 96.586037 is: 2 1 20 0 0 0 88 1358 1469 41 -1 3 1 20 1 0 0 88 1358 1469 41 -1 4 1 20 1 1 0 88 1358 1469 41 -1 5 1 20 1 1 1 88 1358 1469 41 95.000000 2 1 21 0 0 0 151 1386 1350 19 -1 3 1 21 1 0 0 151 1386 1350 19 -1 4 1 21 1 1 0 151 1386 1350 19 -1 5 1 21 1 1 1 151 1386 62 18 96.585480 NAME 5 1 21 1 1 2 220 1387 29 18 96.671623 OF 5 1 21 1 1 3 255 1387 142 18 96.085503 AUTHORIZED 5 1 21 1 1 4 405 1386 197 19 95.937332 REPRESENTATIVE 5 1 21 1 1 5 683 1399 2 3 57.820171 . 5 1 21 1 1 6 763 1386 76 18 96.874191 PHONE 5 1 21 1 1 7 846 1386 94 18 96.387924 NUMBER 5 1 21 1 1 8 1094 1386 160 18 96.398399 RELATIONSHIP 5 1 21 1 1 9 1261 1386 30 18 93.237808 TO 5 1 21 1 1 10 1297 1387 204 18 91.268204 APPLICANT/CLIENT 2 1 22 0 0 0 129 1505 1425 38 -1 3 1 22 1 0 0 129 1505 1425 38 -1 4 1 22 1 1 0 129 1505 1425 38 -1 5 1 22 1 1 1 129 1505 1425 38 95.000000 2 1 23 0 0 0 144 1537 495 19 -1 3 1 23 1 0 0 144 1537 495 19 -1 4 1 23 1 1 0 144 1537 495 19 -1 5 1 23 1 1 1 144 1538 105 18 96.263748 ADDRESS 5 1 23 1 1 2 257 1538 30 18 97.004097 OF 5 1 23 1 1 3 293 1538 141 18 95.837761 AUTHORIZED 5 1 23 1 1 4 442 1537 197 18 95.837761 REPRESENTATIVE 2 1 24 0 0 0 85 1646 1467 43 -1 3 1 24 1 0 0 85 1646 1467 43 -1 4 1 24 1 1 0 85 1646 1467 43 -1 5 1 24 1 1 1 85 1646 1467 43 95.000000 2 1 25 0 0 0 147 1676 1349 19 -1 3 1 25 1 0 0 147 1676 1349 19 -1 4 1 25 1 1 0 147 1676 1349 19 -1 5 1 25 1 1 1 147 1676 62 18 96.879662 NAME 5 1 25 1 1 2 216 1676 29 19 96.587524 OF 5 1 25 1 1 3 252 1677 142 18 95.958687 AUTHORIZED 5 1 25 1 1 4 401 1676 197 18 95.746193 REPRESENTATIVE 5 1 25 1 1 5 758 1676 76 18 96.103500 PHONE 5 1 25 1 1 6 842 1676 93 18 96.103500 NUMBER 5 1 25 1 1 7 1090 1676 160 17 96.339561 RELATIONSHIP 5 1 25 1 1 8 1256 1676 31 17 93.244499 TO 5 1 25 1 1 9 1293 1676 203 18 92.705215 APPLICANT/CLIENT 2 1 26 0 0 0 83 1824 1467 42 -1 3 1 26 1 0 0 83 1824 1467 42 -1 4 1 26 1 1 0 83 1824 1467 42 -1 5 1 26 1 1 1 83 1824 1467 42 95.000000 2 1 27 0 0 0 146 1858 495 19 -1 3 1 27 1 0 0 146 1858 495 19 -1 4 1 27 1 1 0 146 1858 495 19 -1 5 1 27 1 1 1 146 1859 105 18 96.844620 ADDRESS 5 1 27 1 1 2 259 1859 30 18 96.919182 OF 5 1 27 1 1 3 294 1859 142 18 96.382378 AUTHORIZED 5 1 27 1 1 4 444 1858 197 18 96.057274 REPRESENTATIVE 2 1 28 0 0 0 81 2023 998 21 -1 3 1 28 1 0 0 81 2023 998 21 -1 4 1 28 1 1 0 81 2023 998 21 -1 5 1 28 1 1 1 81 2026 54 14 96.294403 Client 5 1 28 1 1 2 141 2026 96 18 93.447205 Signature: 5 1 28 1 1 3 1031 2023 48 16 96.096329 Date: 2 1 29 0 0 0 84 2062 1484 30 -1 3 1 29 1 0 0 84 2062 1484 30 -1 4 1 29 1 1 0 84 2062 1484 30 -1 5 1 29 1 1 1 84 2062 64 27 83.737534 CSF 5 1 29 1 1 2 125 2058 20 39 91.418571 14 5 1 29 1 1 3 155 2073 60 18 95.914970 (01/08) 5 1 29 1 1 4 220 2074 112 16 95.840431 Authorization 5 1 29 1 1 5 339 2074 28 14 96.892921 For 5 1 29 1 1 6 373 2073 69 15 95.860939 Release 5 1 29 1 1 7 448 2073 16 15 96.860832 of 5 1 29 1 1 8 470 2073 95 15 83.204262 Information 5 1 29 1 1 9 571 2081 6 3 92.567986 - 5 1 29 1 1 10 582 2073 91 15 96.651596 Authorized 5 1 29 1 1 11 680 2072 127 20 95.864540 Representative 5 1 29 1 1 12 1454 2073 51 15 90.841476 PAGE 5 1 29 1 1 13 1513 2074 6 13 90.841476 1 5 1 29 1 1 14 1528 2073 26 15 92.957748 OF 5 1 29 1 1 15 1561 2073 7 14 83.674820 1 2 1 30 0 0 0 245 2024 1302 39 -1 3 1 30 1 0 0 245 2024 1302 39 -1 4 1 30 1 1 0 245 2024 1302 39 -1 5 1 30 1 1 1 245 2024 1302 39 95.000000 2 1 31 0 0 0 84 2040 1486 47 -1 3 1 31 1 0 0 84 2040 1486 47 -1 4 1 31 1 1 0 84 2040 1486 47 -1 5 1 31 1 1 1 84 2040 1486 47 95.000000

REQUEST FOR AND AUTHORIZATION TO RELEASE HEALTH INFORMATION PRIVACY ACT AND PAPER WORK REDUCTION ACT INFORMATION: The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Act. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless is displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this form will average 2 minutes. This includes the time it will take to read the instructions, gather the necessary facts and fill out this form. The execution of this form does not authorize the release of information other than that specifically described below.

The information requested on this form is solicited under Title 38 U.S.C. The form authorizes release of information in accordance with the Health Insurance Portability and Accountability Act, 45 CFR Parts 160 and 164; 5 U.S.C. 552a; and 38 U.S.C. 5701 and 7332 that you specify. Your disclosure of the information requested on this form is voluntary. However, if information needed to locate records for release is not furnished completely and accurately, VA will be unable to comply with the request. The Veterans Health Administration may not condition the provision of treatment, payment, enrollment in the VA Health Care Program, or eligibility for benefits on the signing of an authorization, except for research-related treatment where an authorization for the use or disclosure of individually - identifiable health information for such research is required. VA may disclose the information that you put on the form as permitted by law. VA may make a "routine use" disclosure of the information as outlined in the Privacy Act system of records notices identified as 24VA10A7 "Patient Medical Record - VA", 08VA05 "Employee Medical File System Records (Title 38)-VA" and in accordance with the Notice of Privacy Practices. VA may also use this information to identify Veterans and person claiming or receiving VA benefits and their records, and for other purposes authorized or required by law. TO: DEPARTMENT OF VETERANS AFFAIRS (Name and Address of VA Health Care Facility) VA Palo Alto Health Care System 3801 Miranda Ave. Palo Alto, CA 94304

LAST NAME- FIRST NAME- MIDDLE NAME DATE OF BIRTH (mm/dd/yyyy)

PATIENT'S MAILING ADDRESS (including City, State and Zip Code)

NAME AND ADDRESS OF ORGANIZATION, INDIVIDUAL, OR TITLE OF INDIVIDUAL TO WHOM INFORMATION IS TO BE RELEASED Santa Cruz Veterans Court (701 Ocean St, Santa Cruz, CA 95060), all affiliated individuals, agencies, attorneys, and court evaluator - see attached listing.

PURPOSE(S) OR NEED: Information is to be used by the requestor for:

TREATMENT BENEFITS LEGAL EMPLOYMENT OTHER (Please specify)

INFORMATION REQUESTED: Check applicable box(es) and state the extent or nature of information to be provided:

HEALTH SUMMARY (Prior 2 Years)

INPATIENT DISCHARGE SUMMARY (Dates):

PROGRESS NOTES:

SPECIFIC CLINICS (Name & Date Range):

SPECIFIC PROVIDERS (Name & Date Range):

DATE RANGE:

OPERATIVE/CLINICAL PROCEDURES (Name & Date):

LAB RESULTS:

SPECIFIC TESTS (Name & Date): All drug tox screens as deemed relevant by the court

DATE RANGE:

RADIOLOGY REPORTS (Name & Date):

LIST OF ACTIVE MEDICATIONS:

FLU VACCINATION (Dose, Lot Number, Date & Location):

OTHER (Describe): All relevant medical record information needed for court supervision

VA FORM DEC 2020 10-5345 Page 1 of 2

LAST NAME- FIRST NAME- MIDDLE NAME DATE OF BIRTH (mm/dd/yyyy)

SENSITIVE DIAGNOSES: REVIEW AND, IF APPROPRIATE, COMPLETE WHEN RELEASE IS FOR ANY PURPOSE OTHER THAN TREATMENT.

I request and authorize Department of Veterans Affairs to release the information pertaining to the condition(s) below for the non-treatment purpose(s) listed in this authorization. DRUG ABUSE ALCOHOLISM OR ALCOHOL ABUSE SICKLE CELL ANEMIA

HUMAN IMMUNODEFICIENCY VIRUS (HIV)

I understand that information on these sensitive diagnoses may be released for treatment purposes without me checking the above boxes, and will be released even if the boxes are unchecked unless I indicate by checking the box below that I do not want this information released for this specific disclosure. I do not want sensitive diagnoses released for treatment purposes under this specific authorization. I realize this does not impact other future requests unrelated to this authorization.

AUTHORIZATION: I certify that this request has been made freely, voluntarily and without coercion and that the information given above is accurate and complete to the best of my knowledge. I understand that I will receive a copy of this form after I sign it. I may revoke this authorization in writing, at any time except to the extent that action has already been taken to comply with it. Written revocation is effective upon receipt by the Release of Information Unit at the facility housing records. Any disclosure of information carries with it the potential for unauthorized redisclosure, and the information may not be protected by federal confidentiality rules.

I understand that the VA health care provider's opinions and statements are not official VA decisions regarding whether I will receive other VA benefits or, if I receive VA benefits, their amount. They may, however, be considered with other evidence when these decisions are made at a VA Regional Office that specializes in benefit decisions.

EXPIRATION: Without my express revocation, the authorization will automatically expire (select one of the following):

AFTER ONE-TIME DISCLOSURE, IF ALL NEEDS ARE SATISFIED

ON (mm/dd/yyyy) (enter a future date other than date signed by patient)

UNDER THE FOLLOWING CONDITION(S): Upon completion of court program

PATIENT SIGNATURE (Sign in ink) DATE (mm/dd/yyyy)

LEGAL REPRESENTATIVE SIGNATURE (if applicable) (Sign in ink) DATE (mm/dd/yyyy)

PRINT NAME OF LEGAL REPRESENTATIVE RELATIONSHIP TO PATIENT

FOR VA USE ONLY

TYPE AND EXTENT OF MATERIAL RELEASED Veterans Justice Outreach (VJO) Specialist will provide summary of progress via written, verbal, telephonic and/or secured email that is required by court to determine program eligibility and for monitoring of patient progress in treatment and compliance with legal conditions of Veteran Treatment Court participation, inclusive of all relevant medical record information both past and future. Information will include but not be limited to: diagnoses (medical, mental health, and substance/alcohol), relevant labs, medical diagnoses, progress in treatment programming, developmental, social, financial and military data as relevant to court/legal circumstances to the designated court team and additional guests as permitted by authorization. Information will be shared with the home court to determine eligibility as needed and at regular intervals by the Court Team in Veterans Court to adequately assess progress of Veteran and compliance with court and probation guidelines. The authorization will expire upon Veteran discharge or successful completion of court program and probation period which may last longer than the court program. Medical record information is subject to review in open court docket. Affiliated parties include public defenders, district attorneys, probation officers, peer mentors, veterans service officer, veterans service advocate, court coordinator, MENtors program staff, and judges.

DATE RELEASED (mm/dd/yyyy) RELEASED BY:

VA FORM 10-5345, DEC 2020 Page 2 of 2

Standard Form 180 (Rev. 07/2023) (Page 1) a Prescribed by NARA (36 CFR 1233.18 (d)) Previous edition unusable Authorized for local reproduction OMB No. 3095-0029 Expires 04/30/2024 REQUEST PERTAINING TO MILITARY RECORDS Requests can be submitted online using eVetRecs at https://www.archives.gov/veterans/military-service-records/ To ensure the best possible service, please thoroughly review the accompanying instructions before filling out this form. PLEASE PRINT LEGIBLY OR TYPE BELOW. SECTION I - INFORMATION NEEDED TO LOCATE RECORDS (Furnish as much information as possible.) 1, NAME USED DURING SERVICE (last, first, full middle) 2. SOCIAL SECURITY # 3. DATE OF BIRTH | 4. PLACE OF BIRTH 5. SERVICE, PAST AND PRESENT (For an effective records search, it is important that ALL service be shown below.) 7p SERVICE NUMBER BRANCH OF SERVICE DATE DATE OFFICER |ENLISTED (If unknown, write “unknown”) ° ENTERED RELEASED , a. ACTIVE b. RESERVE ce. NATIONAL GUARD 6. PLEASE LIST LAST FOUR DUTY STATIONS, IF KNOWN: 1. 2 oo 7. IS THIS PERSON DECEASED? [Jno []YES - MUST provide Date of Death if veteran is deceased: . DID THIS PERSON RETIRE FROM MILITARY SERVICE? []No im YES 3 4. SECTION II - INFORMATION AND/OR DOCUMENTS REQUESTED

1. CHECK THE ITEM(S) YOU ARE REQUESTING: O O O O O DD Form 214 or equivalent: Year(s) in which form(s) issued to veteran (Date of Separation): This form contains information used to verify military service. An UNDELETED DD Form 214 is ordinarily required to determine eligibility for benefits. If you request a DELETED copy, the following items will be blacked out: authority for separation, reason for separation, reenlistment eligibility code, separation (SPD/SPN) code, and, for separations after June 30, 1979, character of separation and dates of time lost. Please note — recent veterans may be able to request a DD Form 214 through milConnect by visiting: https://www.va.gov/records/get-military-service-records/ An UNDELETED copy will be sent UNLESS YOU SPECIFY A DELETED COPY by checking this box: OC I want a DELETED copy. Official Military Personnel File (OMPF): The OMPF may include duty stations and assignments, training and qualifications, awards and decorations received, disciplinary actions, administrative remarks, enlistment and/or discharge information (including DD Form 214, Report of Separation, or equivalent), and other personnel actions. Detailed information about the veteran's participation in battles and their military engagements is NOT contained in the record. Medical Records: Includes health (outpatient), extended ambulatory, and dental records. If inpatient/hospitalization records are requested, please specify below. I request inpatient/hospitalization records from (facility), last treated in (year). (NOTE: Fields are required) If available, you may receive copies of inpatient narrative summaries, operative reports, discharge summaries, etc. contained in the record. Dental Records: Please check this box if ONLY dental records are needed from the medical record. Other (Please Specify):
2. PURPOSE: (Providing information about the purpose of the request is voluntary; however, it may help to provide the best possible response and may result in a faster reply. Information provided will in no way be used to make a decision to deny the request.) O Explain here: Benefits (explain) [[] Employment (1 VALoan Programs [[] Medical [] Genealogy [[] Correction [[] Personal [[] Other (explain) SECTION III - RETURN ADDRESS AND SIGNATURE
3. REQUESTER NAME: 2. RELATIONSHIP TO VETERAN:

Xavier Bianchi Veteran Advocate Santa Cruz County Iam the VETERAN’S LEGAL GUARDIAN (MUST submit copy of Court Appointment) or AUTHORIZED REPRESENTATIVE (MUST submit copy of Authorization Letter or Power of Attorney) [__JoTHER (Specify):

| Tam the MILITARY SERVICE MEMBER OR VETERAN identified in

Section 1, above. Tam the DECEASED VETERAN’S NEXT-OF-KIN (MUST submit Proof of Death. See item 2a on instruction sheet.) SEND INFORMATION/DOCUMENTS TO: (Please print or type. See item 4 on accompanying instructions.) 5. AUTHORIZATION SIGNATURE: I declare (or certify, verify, or state) under penalty of perjury under the laws of the United States of America that the information in this Section 3 is true and correct and that I authorize the release Name of the requested information. (See items 2a or 3a on the accompanying instructions 842 Front St. sheet. Without the Authorization Signature of the veteran, next-of-kin of deceased Street Address Apt. # veteran, veteran's legal guardian, authorized government agent, or other authorized representative, only limited information can be released unless the request is Santa Cruz CA 95060 archival. No signature is required if the request is for archival records.) City State ZIP Code 831-281-0388 831-458-7116 i e Fax Number Daytime Phone Signature Required — Do not print Date

• This form is available at https://www.archives.gov/veterans/military-service-records/standard- xavier.bianchi@santacruzcountyca.gov form-180.html on the National Archives and Records Administration (NARA) website. * Email Address

General Release Signature: ____________________________________________ General Consent: This consent remains in effect until my evaluation for or participation in services. Recipients of this information may re-disclose and use this information only in connection with their official duties. Check all that apply: ☐ ALL ☐ Encompass Janus Positive Discipline ☐ ☐ ☐ Barrios Unidos ☐ First 5 Santa Cruz County ☐ Leaders in Community Alt. ☐ Sobriety Works County Office of Educ. Goodwill Mentors Streets to Schools ☐ ☐ ☐ ☐ Collaborative Court Hope Services Monarch Services Volunteer Center ☐ ☐ ☐ ☐ Conflict Resolution Center New Life Community Svc. ☐__________________________ ☐ ☐ Health Services Agency ☐ Mental Health (MH)/Medical Signature: ____________________________________________ For Mental Health/Medical Consent: A recipient of medical information pursuant to this authorization may not further disclose the medical information except in accordance with a new authorization that meets the requirements of California Health and Safety Code section 56.11, or as specifically required or permitted by law. Check all that apply: ☐ ALL ☐ Encompass Janus Positive Discipline ☐ ☐ Leaders in Community Alt. ☐ Sobriety Works ☐ Barrios Unidos ☐ First 5 Santa Cruz County ☐ County Office of Educ. Goodwill Mentors Streets to Schools ☐ ☐ ☐ ☐ Collaborative Court Hope Services Monarch Services Volunteer Center ☐ ☐ ☐ ☐ Conflict Resolution Center New Life Community Svc. ☐ Other: _________________ ☐ ☐ Health Services Agency ☐ Substance Use Disorder (SUD) Signature: ____________________________________________ For Substance Use Disorder Consent: Substance use disorder records are protected under the federal regulations governing Confidentiality of Substance Use Disorder Patient Records, 42 C.F.R. Part 2, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. Check all that apply: ☐ ALL ☐ Encompass Janus Positive Discipline ☐ ☐ Leaders in Community Alt. ☐ Sobriety Works ☐ Barrios Unidos ☐ First 5 Santa Cruz County ☐ County Office of Educ. Goodwill Mentors Streets to Schools ☐ ☐ ☐ ☐ Collaborative Court Hope Services Monarch Services Volunteer Center ☐ ☐ ☐ ☐ Conflict Resolution Center Health Services Agency New Life Community Svc. ☐ Other: _________________ ☐ ☐ ☐

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I, ____________________________________________________, __________________ (Print name of client or client’s representative) (Print date of birth) hereby authorize the Santa Cruz County Probation Department to disclose and receive confidential information contained in their file to the agencies indicated above.

I understand that any of this information may be used by the Probation Officer in any report to the Court and, therefore, be available to the District Attorney and my attorney. I may revoke my consent verbally or in writing at any time (except to the extent that action has already been taken), and if not earlier revoked, it shall terminate one year from today on (date): _____________.

Signature: ___________________________ Date: _________ Witnessed by: ________________________ Signature of client or client’s representative Signature Legal relationship of above signer: _______________________ Date: ______________

ROI English Rev. 9-11-23 Page 1 of 1