San Luis Obispo — Mental Health Records Request

Source: https://www.slo.courts.ca.gov/system/files/mental-health-records-request.pdf

COUNTY OF SAN LUIS OBISPO

HEALTH AGENCY

BEHAVIORAL HEALTH DEPARTMENT

Michael Hill, Health Agency Director

Anne Robin, LMFT Behavioral Health Director

Behavioral Health Records Request Procedure

All requests for protected health information (PHI) require the individual’s written

consent. Each request for behavioral health records must include a completed Release of Information signed by the individual.

Send all behavioral health record requests to: Central Health Information Fax: (805) 781-4271 Mail: 2178 Johnson Ave San Luis Obispo, CA 93401 Phone: (805) 781-1403

CONFIDENTIAL PATIENT INFORMATION – NOT TO BE FORWARDED

This information has been disclosed to you from records that are confidential and protected by state confidentiality law that protects mental health records (See California Welfare and Institutions Code Section 5328). Information subject to release in accordance with Federal Privacy Act of 1974 (Public Law 93-597). This information has been disclosed to you from records protected by Federal confidentiality rules (42

CFR, Part 2, Section 2.32). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. Total pages included:

The Health Agency complies with Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex or any other protected class

County of San Luis Obispo Health Agency

2180 Johnson Avenue | San Luis Obispo, CA 93401 | (P) 805-781-4719 | (F) 805-781-1273

slobehavioralhealth.org | slocounty.ca.gov

Name: Case#: Page: 1 of 4 Type: BH Auth to Use/Disclose PHI Date:

San Luis Obispo County Behavioral Health Department AUTHORIZATION TO USE AND-OR DISCLOSE PROTECTED HEALTH INFORMATION

Last Name First Name

Address

City/State/Zip Home Phone

DOB SSN, last 4 digits:

San Luis Obispo County Behavioral Health Department is authorized to:

Receive/Obtain information from: □ Yes □ No Disclose information to: □ Yes □ No

Exchange information between:

SLO Drug and Alcohol Services □ Yes □ No □ N/A
SLO Mental Health Services □ Yes □ No □ N/A
SLO Public Health Services □ Yes □ No □ N/A

Name of Party to Receive and-or Disclose Information:

Name:

Address:

City/State/Zip

Phone: Fax:

Relationship to Client:

Description of information to disclose:

□ All my substances use program records □ All my mental health records □ All my public health records

□ Current Diagnosis Review □ Current Psychiatric Evaluation □ Discharge Summary □ Current Intake Assessment □ Medication History □ Current Treatment Plan □ Treatment Summary □ Nursing Assessment □ Progress Report □ Laboratory Results

□ Other (Specify) □ Level of Care and Services Recommended □ Attendance Record/Letter □ Payment Record □ Drug Testing Results

Name: Case#: Page: 2 of 4 Type: BH Auth to Use/Disclose PHI Date:

I specifically authorize the use and-or disclosure of the following health information:

Alcohol and/or Drug Abuse Treatment Program Records (Required to authorize exchange of information between SLO DAS and SLO MHS) □ Yes □ No

HIV/AIDS Testing, Diagnosis and/or Treatment Information □ Yes □ No

Purpose of disclosure:

Is this limited to a single disclosure? □ Yes □ No

If yes, explain:

If no, this authorization will remain in effect from the date of this authorization until:

I understand that:

1. I understand that I have the right to receive a copy of this authorization.

2. This authorization includes written, electronic and/or verbal disclosure.

3. A copy of this authorization is as valid as an original.

4. I have the right to revoke this authorization by sending a signed notice stopping this authorization: SLO Health Agency Medical Records: 2178 Johnson Ave., San Luis Obispo, CA 93401 or via e-mail at privacy@co.slo.ca.us; or call (855) 326-9623

5. This authorization will cease on the date my valid revocation request is received. I also understand that

   any information released prior to revoking this authorization is not a breach of my confidentiality.
6. A form known as The Notice of Privacy Practices which is given to clients who receive medical services, provides instructions should I chose to revoke my authorization and includes limitations on my revocation. I can access this notice on the internet at: http://www.slocounty.ca.gov/health.htm
7. Treatment cannot be denied to me if I refuse to sign this authorization. However, outside agencies that require protected health information to provide various services for me may not be able to do so.
8. The information will only be used as described in this authorization. If the organization or person I have authorized to receive the information is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations.
9. Records and copies obtained relating to outpatient psychotherapy shall be returned or destroyed at the expiration date of this authorization except those obtained for treatment and diagnosis purposes.

10. I understand that alcohol and/or drug treatment records are protected under the federal regulations

    governing confidentiality of alcohol and drug abuse patient records. These include; 42 C.F.R. Part 2, the Health Insurance Portability and Accountability Act of 1996 (HIPPA), and 45 C.F.R. Pts 160 and 164. Records cannot be re-disclose without my written consent unless otherwise provided for in the regulations.

I have read and understand the terms of this authorization and I have had an opportunity to ask questions about the use/or disclosure of my health information. By my signature below, I hereby knowingly and voluntarily authorize San Luis Obispo County Behavioral Health Department to use and/or disclose my health

Name: Case#: Page: 3 of 4 Type: BH Auth to Use/Disclose PHI Date:

information in the manner described above.

A minor client's signature (12 - 17) is required to disclose information concerning care for mental health conditions and/or alcohol and drug abuse issues.

Form HIPAUTHDIS; Version 2.09; 03/18/2021

Name: Case#: Page: 4 of 4 Type: BH Auth to Use/Disclose PHI Date:

Signatures

Signature Signature Line Heading Name Date Time

C Client

S Staff Witness

S LPHA

Name: Case#: Page: 1 of 4 Type: BH Auth to Use/Disclose PHI Date:

San Luis Obispo County Behavioral Health Department AUTHORIZATION TO USE AND-OR DISCLOSE PROTECTED HEALTH INFORMATION

Last Name First Name

Address

City/State/Zip Home Phone

DOB SSN, last 4 digits:

San Luis Obispo County Behavioral Health Department is authorized to:

Receive/Obtain information from: □ Yes □ No Disclose information to: □ Yes □ No

Exchange information between:

SLO Drug and Alcohol Services □ Yes □ No □ N/A
SLO Mental Health Services □ Yes □ No □ N/A
SLO Public Health Services □ Yes □ No □ N/A

Name of Party to Receive and-or Disclose Information:

Name:

Address:

City/State/Zip

Phone: Fax:

Relationship to Client:

Description of information to disclose:

□ All my substances use program records □ All my mental health records □ All my public health records

□ Current Diagnosis Review □ Current Psychiatric Evaluation □ Discharge Summary □ Current Intake Assessment □ Medication History □ Current Treatment Plan □ Treatment Summary □ Nursing Assessment □ Progress Report □ Laboratory Results

□ Other (Specify) □ Level of Care and Services Recommended □ Attendance Record/Letter □ Payment Record □ Drug Testing Results

Name: Case#: Page: 2 of 4 Type: BH Auth to Use/Disclose PHI Date:

I specifically authorize the use and-or disclosure of the following health information:

Alcohol and/or Drug Abuse Treatment Program Records (Required to authorize exchange of information between SLO DAS and SLO MHS) □ Yes □ No

HIV/AIDS Testing, Diagnosis and/or Treatment Information □ Yes □ No

Purpose of disclosure:

Is this limited to a single disclosure? □ Yes □ No

If yes, explain:

If no, this authorization will remain in effect from the date of this authorization until:

I understand that:

1. I understand that I have the right to receive a copy of this authorization.

2. This authorization includes written, electronic and/or verbal disclosure.

3. A copy of this authorization is as valid as an original.

4. I have the right to revoke this authorization by sending a signed notice stopping this authorization: SLO Health Agency Medical Records: 2178 Johnson Ave., San Luis Obispo, CA 93401 or via e-mail at privacy@co.slo.ca.us; or call (855) 326-9623

5. This authorization will cease on the date my valid revocation request is received. I also understand that

   any information released prior to revoking this authorization is not a breach of my confidentiality.
6. A form known as The Notice of Privacy Practices which is given to clients who receive medical services, provides instructions should I chose to revoke my authorization and includes limitations on my revocation. I can access this notice on the internet at: http://www.slocounty.ca.gov/health.htm
7. Treatment cannot be denied to me if I refuse to sign this authorization. However, outside agencies that require protected health information to provide various services for me may not be able to do so.
8. The information will only be used as described in this authorization. If the organization or person I have authorized to receive the information is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations.
9. Records and copies obtained relating to outpatient psychotherapy shall be returned or destroyed at the expiration date of this authorization except those obtained for treatment and diagnosis purposes.

10. I understand that alcohol and/or drug treatment records are protected under the federal regulations

    governing confidentiality of alcohol and drug abuse patient records. These include; 42 C.F.R. Part 2, the Health Insurance Portability and Accountability Act of 1996 (HIPPA), and 45 C.F.R. Pts 160 and 164. Records cannot be re-disclose without my written consent unless otherwise provided for in the regulations.

I have read and understand the terms of this authorization and I have had an opportunity to ask questions about the use/or disclosure of my health information. By my signature below, I hereby knowingly and voluntarily authorize San Luis Obispo County Behavioral Health Department to use and/or disclose my health

Name: Case#: Page: 3 of 4 Type: BH Auth to Use/Disclose PHI Date:

information in the manner described above.

A minor client's signature (12 - 17) is required to disclose information concerning care for mental health conditions and/or alcohol and drug abuse issues.

Form HIPAUTHDIS; Version 2.09; 03/18/2021

Name: Case#: Page: 4 of 4 Type: BH Auth to Use/Disclose PHI Date:

Signatures

Signature Signature Line Heading Name Date Time

C Client

S Staff Witness

S LPHA