San Mateo — Consent to Release of Information for Veterans Treatment Court

Source: https://sanmateo.courts.ca.gov/system/files/local-forms/vtc-02.pdf

Consent to Release of Information for Veterans Treatment Court

TO: San Mateo County Adult Probation San Mateo County Mental Health Division San Mateo County General Hospital San Mateo County Forensic Mental Health San Mateo County District Attorney San Mateo County Superior Court Maguire Correctional Facility—Medical Records, Mental Health Records , Attorney at Law United States Department of Veterans Administration Other:________

I, ____________________, hereby authorize any of the above named persons or organizations, to

release to my attorney, ________________________, to San Mateo County Adult Probation, to San Mateo County Mental Health Division, San Mateo County General Hospital, San Mateo County Forensic Mental Health, San Mateo County District Attorney, San Mateo County Superior Court, Maguire Correctional Facility—Medical Records & Mental Health Records, United States Department of Veterans Administration, and to Honorable John L. Grandsaert, Judge of the Superior Court, or their designees, any and all information and/or records from my files held by the individuals or organizations named above relating to my evaluation and treatment for any mental illness or mental health related issues. This includes, but is not limited to, the following records and reports: hospitalizations, correctional, medical, psychological, psychiatric, probation and rehabilitation (including alcohol and drug rehabilitation), consultation reports and/or diagnostic data, medication list, as well as any files prepared in connection with prior civil commitments.

I understand that this information will be used for pending judicial proceedings, and for the

determination of my eligibility for the Veterans Treatment Court, and for the determination by San Mateo Mental Health and San Mateo Adult Probation Department of my suitability for receiving such treatment.

I understand that by signing this authorization, I agree that my attorney may further disclose my

medical/mental health information in connection with his/her representation of me when he/she deems such disclosure necessary for the adjudication of the legal proceedings, i.e., criminal prosecution, in which I am involved, to-wit: People v. ____________________________, case number(s) ___________________, now pending in the San Mateo County Superior Court.

I understand that the recipient may not lawfully further use or disclose the health information unless

another authorization is obtained from me or unless such use or disclosure is specifically required or permitted by law.

The providers of the information requested shall not condition treatment or payment based on this

authorization. I understand that I need not sign this authorization and that if this authorization is not signed, the information shall not be released except when specifically required or permitted by law.

I further understand that I may revoke this authorization at any time by writing to, or otherwise notifying my attorney, or any of the addressees listed above, or the Court, of my desire to revoke this authorization.

Consent to Release of Information for Veterans Treatment Court

Form adopted for Mandatory Use Pen.Code § 1170.9 Local Court Form VTC 02 [Rev. May 2012]

I understand that revocation will not apply to information that has already been released in response to this authorization.

You are specifically authorized to photocopy the records mentioned above and to release copies to those

named above as authorized recipients. A photocopy of this authorization shall be as valid as the original.

I understand that I have a right to receive a copy of this authorization if I so desire.

This authorization becomes effective on the date of my signature, and expires in one year from that date;

however, if I am accepted into Veterans Treatment Court, the release will expire upon termination of the treatment ordered by the Court, or earlier if I execute a revocation in writing.

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Date Signature

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Print or type name

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Social Security Number

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Sheriff’s Office ID Number

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Date Witness Signature

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Date Signature for revocation of release

Dated: ______________ ________________________________________ Veteran’s Signature

Consent to Release of Information for Veterans Treatment Court

Form adopted for Mandatory Use Pen.Code § 1170.9 Local Court Form VTC 02 [Rev. May 2012]