Sonoma — Blank Provider Release of Information English

Source: https://sonoma.courts.ca.gov/system/files/forms-and-filings/blank-roi-english-fillable.pdf

Authorization for the Sonoma County Multi-Disciplinary Team to Share and Use Information Rev. 1/1/25

Client's Legal Name: DOB

Last 4

Also Known As (Optional Alt Name): SSN Digits Sonoma County coordinates teams of health care providers, social service agencies, homeless services, and other agencies to help clients get services they need. By signing this form, you will allow teams from these agencies to share information so they can help you. If you don’t sign this form, you can still seek services from these organizations on your own, but you will not be eligible for services from the Sonoma County Multi-Disciplinary Team.

AUTHORIZATION TO DISCLOSE AND EXCHANGE MY HEALTH AND PERSONAL INFORMATION INITIAL HERE TO ALLOW ALL AGENCIES LISTED BELOW TO SHARE YOUR INFORMATION: Initial I've written my initials to acknowledge that the County agencies, health care providers, and Here other organizations listed below are allowed to share my information with each other. Sonoma County Departments: Other Sonoma County Departments/Agencies Health Services Child Support Services Drug & Alcohol Services Community Development Comm. /Housing Authority Homelessness Services Probation Department Mental Health Services Public Defender's Office Public Health Sonoma County Sheriff's Medical Services Human Services City Based Homeless Services Adult and Aging including Veterans Services City of Healdsburg Homelessness Services Economic Assistance City of Petaluma Homeless Services Employment & Training City of Rohnert Park Homeless Services Family, Youth and Children Services City of Santa Rosa Homeless Services City of Sebastopol Homeless ServicesOther Agencies: (Community Partners) City of Sonoma Homeless ServicesCommunity Health Services Homeless/Housing Service Agencies Alexander Valley Health Care Buckelew Programs Alliance Medical Center Catholic Charities of Santa Rosa Petaluma Health Center Community Support Network Santa Rosa Community Health Centers COTS Sonoma County Indian Health Project HomeFirst Services Sonoma Valley Community Health Centers Homeless Action Sonoma (HAS) West County Health Centers Interfaith Shelter Network Hospital Systems Interlink Self-Help Center Healdsburg District Hospital and clinics Nation’s Finest – Veteran’s Services Reach for Home Kaiser Permanente Hospitals and clinics Redwood Gospel Mission Providence Health System and clinics SHARE Sonoma County Sonoma Valley Hospital and clinics Sonoma Applied Village Services Sutter Hospitals and clinics (SAVS) Sonoma Overnight Support Other Service Agencies St. Vincent de Paul Community Action Partnership The Living Room Face to Face HIV Services West County Community Services Family Justice Center Felton Institute Substance Use Disorder Services Goodwill Industries Drug Abuse Alternative Center Legal Aid of Sonoma County Hilltop Recovery Services North Bay Regional Center Santa Rosa Treatment Program Women's Recovery Services Partnership Health Plan Siyan Clinical Corp. Youth Services TLC Child and Family Services Verity Voices Sonoma Youth Center YWCA

Other: Sonoma County Superior Court Other: JBCT - Recovery Solutions Other: Sonoma County District Attorney Office Other:

Authorization for the Sonoma County Multi-Disciplinary Team to Share and Use Information Rev. 1/1/25

This authorization to release information will expire 5 years from the date it is signed; or will expire on: (Not to exceed 5 Years.)

HEALTH AND PERSONAL INFORMATION THAT CAN BE SHARED BY THE IDENTIFIED AGENCIES

THIS AUTHORIZATION ALLOWS DISCLOSURE OF ALL YOUR HEALTH, SOCIAL SERVICES, AND PROBATION RECORDS The agencies listed on this authorization form can share all information from your health care records or personal records. The information may come from your past, present or future physical health provider, mental health provider, or substance use treatment provider. The information may also come from your Social Services records, Justice Records (if any) or the records of any other agency listed on this authorization form. The information the agencies share may be written or spoken.

Initial Here Initial here to indicate you understand we will share your mental health information.

Initial Here Initial here to indicate you understand we will share your Substance Use Program information from past, present and future treating providers.

Initial Here Initial here to indicate you understand we will share your HIV/Aids information, if any.

PURPOSES AND LIMITATIONS ON THE USE OF YOUR HEALTH AND PERSONAL INFORMATION The agencies listed on this authorization form will use the information they share to refer you to services or to work with other agencies to provide services that will improve your health and well-being. These services may be in areas like health care, housing, employment, education, nutrition, parenting, child welfare, and/or other traditional social services. This information may also be used for research purposes.

I understand that: I have a right to receive a copy of this authorization and have been offered a copy. I have the right to tell you to stop sharing my information by writing a letter or email to: Sonoma County Privacy Officer: 1450 Neotomas Ave, Santa Rosa, CA, 95405 or by e-mail at DHS-Privacy&Security@Sonoma-County.org ; or call (707) 565-5703 If I tell you to stop sharing my information, you will stop on the day I tell you to stop, but it will not affect information you already shared. I understand I don't have to sign this form and my information won't be shared if I don't sign it, however I will not be able to participate with the Multi-Disciplinary Team. If I want to see these services through individual organizations, they won't deny me treatment, enrollment, or eligibility for benefits because I didn't sign this form; however, I won’t be served by the IMDT and some services and treatment can't happen if I don't allow my information to be shared. Information that the agencies share with each other may then be shared by the person who gets the information, except for certain federally protected drug and alcohol records. I understand that some of the information that is shared may no longer be protected by privacy laws; for example, if I allow information to be shared with a family member. Agency of Employee Employee Name: filling out this form:

Client Signature: Print Name: Date:

Representative Signature: Relation: Date: