Butte — Request and Authorization to Release Health Information

Source: https://www.butte.courts.ca.gov/system/files/mil-request-and-authorization-release-health-information.pdf

Sparse pages use OCR; original PDF remains authoritative.

Department of Veterans Affairs 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 the information including the last four of your Social Security Number (SSN) and Date of Birth (used 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 treatment, payment, enrollment or eligibility on signing the authorization. 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 24VA10P2 “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): Northern CA Healthcare System (NCHCS)Chico Outpatient Clinic 1601 Concord Ave, Chico, CA 95928 Or any other VHA hospital system where the Veteran has or will receive services. LAST NAME-FIRST NAME-MIDDLE INITIAL LAST 4 SSN DATE OF BIRTH NAME AND ADDRESS OF ORGANIZATION, INDIVIDUAL, OR TITLE OF INDIVIDUAL TO WHOM INFORMATION IS TO BE RELEASED Butte Superior Court, Butte County Probation, all affiliated individuals, agencies, attorneys, and court evaluator. Veteran agrees to additional guests of the court/research investigators _§ Yes_N PURPOSE(S) OR NEED: Information is to be used by the organization or individual for X Treatment O Benefits Legal O Employment O Other -— Please specify. INFORMATION REQUESTED: Check applicable box(es) and state the extent or nature of information to be provided: O Health Summary (prior 2 years) O Inpatient Discharge Summary (dates): 0 Progress Notes: O Specific clinics (name & date range): 0 Specific providers (name & date range): 0 Date range: 0 Operative/Clinical Procedures (name &date): X Lab results: 0 Specific tests (name & date): € Date range: any substance urine results 0 Radiology Reports (name & date): & List of Active Medications O Flu Vaccination (dose, lot number, date & location) X] Other (describe below) Veteran status, income, contact information, whereabouts & wellbeing, service connected disabilities, items on problem list, hx and current medications, hx and current diagnoses, hx and current treatment, hx and current medical issues/treatment, progress and engagement in treatment, appointments and atten treatment plans. Hance, VA Form 10-5345 Page 1 of 2 SEPT 2018

LAST NAME-FIRST NAME-MIDDLE INITIAL LAST 4 SSN DATE OF BIRTH SENSITIVE DIAGNOSES: REVIEW AND, IF APPROPRIATE, COMPLETE WHEN RELEASE IS FOR ANY PURPOSE OTHER THAN TREATMENT. Irequest and authorize the Department of Veterans Affairs to release the information pertaining to the condition(s) below for the non-treatment purpose(s) listed in this authorization: ODrmg Abuse CO Alcoholism or Alcohol Abuse 1 Sickle Cell Anemia 0 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. OI 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, or because a condition of VA employment mandates the signing of this authorization. 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 information disclosed per this authorization may no longer be protected by Federal confidentiality laws or regulations and may be subject to re-disclosure by the recipient. 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 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 O After one-time disclosure, if all needs are satisfied O On (enter a future date other than date signed by patient) X Under the following condition(s): Upon completion/discharge of court program and probation. PATIENT SIGNATURE DATE (mm/dd/yyyy) LEGAL REPRESENTATIVE SIGNATURE (if applicable) DATE (mm/dd/yyyy) PRINT NAME OF LEGAL REPRESENTATIVE RELATIONSHIP TO PATIENT FOR VA USE ONLY Type and Extent of Material Released: VJ it Provide summary of progress via written, verbal, telephonic and secured email that is required by court for monitoring of patient progress in treatment and compliance with legal conditions of Veterans Treatment Court participation, inclusive of all relevant medical record information both past and future. Information will include but not be limited to: eligibility status; health problems & medical care-current and history, MH diagnoses and treatment-current and history, medications-current and history, substance abuse diagnoses and treatment-current and history, UA & PBT results, \diagnoses (medical, mental health, and substance/alcohol), relevant labs, medical diagnoses, progress in treatment programming, developmental, social, financial and military data as relevant, information will be shared at regular intervals as needed by the court team 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. Date Released: | Released by: VA Form 10-5345 Page 2 of 2 SEPT 2018