By signing this document, I hereby authorize California Psychological Institute (CPI) to request, release and/or exchange mental health/ or health information with the office, clinic, doctor or party listed below to ensure that the client receives appropriate and effective services. I allow the agency to carry out its case management responsibilities; to monitor treatment, health-care operations, and billing and payment; and to inform the court of the child’s medical and/or mental health needs. This form complies with the Health Insurance Portability and Accountability Act (HIPPA), Confidentiality of Medical Information Act (CMIA) and Lanterman-Petris-Short (LPS) Act.

CPI shall not condition treatment or payment based on this authorization. The patient may refuse to sign the authorization. If the authorization is not signed, the information shall not be released except when required by law. Upon request, the patient may inspect or be provided a copy of the protected health information to be disclosed by this authorization.