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.
CPI may disclose, release and exchange information about:
By signing I acknowledge that such release discloses the fact that mental health/health services have been/are being provided.
This disclosure of information* is required for the following purpose(s): ): (check applicable areas)
and shall be limited to releasing the following types of information (initial all applicable areas):
or any information/records indicated, regardless of date.
This authorization may be revoked in writing by the undersigned at any time except, to the extent that action has already been taken. If not revoked, it shall terminate in one year. Once this information is disclosed, how the recipient further discloses it may no longer be protected under federal privacy law (HIPAA).
I understand that I may receive a copy of this authorization.
*For CPI Office Personel Only*
RECORD OF RELEASE OF INFORMATION
The following information was released to the named party specified on the front of this form. Identify the specific dates of the reports, records, items released.
Please print out this page after you have filled it out, then sign it and bring it with you on your first visit.