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Alpine County Behavioral Health Services 75 C Diamond Valley Rd, Markleeville, CA 96120 Phone: (530) 694-1816 Fax: (530) 694-2387 AUTHORIZATION FOR THE USE AND DISCLOSURE OF HEALTH INFORMATION Patient/Client Information: Last Name First Name Birth Date Address City, State Zip Code Phone Person/Organization Authorized to EXCHANGE Information: Name/Organization Phone Address City, State Zip Code Fax Person/Organization Authorized to EXCHANGE Information: Alpine County Behavioral Health 75 C Diamond Valley Rd Markleeville, CA 96120 Phone: [PHONE REDACTED] Fax: [PHONE REDACTED] Information to be Disclosed/Used: (INITIAL all that apply) Mental Health Information Medical Information Alcohol/Drug Information Other List information to be REQUESTED: The purpose of this authorization is to use/disclose Protected Health Information: (Check all that apply) To coordinate care Requested by client Other ---PAGE BREAK--- This authorization is valid for one year, or until Date I, the undersigned, understand: I sign this authorization voluntarily and Alpine County Behavioral Health may not condition treatment, payments, enrollment or eligibility for benefits or services based on this authorization. I may revoke this authorization in writing unless the disclosure has already been made or the disclosure is permitted or required by law. My revocation of this authorization must be in writing, signed by me or on my behalf and delivered to the following address: 75 C Diamond Valley Rd Markleeville, CA 96120 If my Protected Health Information includes alcohol and drug abuse information, I understand that the following statement applies: Federal laws and regulations protect the confidentiality of alcohol and drug abuse records maintained by a program. Generally, disclosure of any information identifying a client as an alcohol or drug abuser is prohibited unless: 1) the client consents in writing, 2) the disclosure is allowed by a court order, 3) the disclosure is made to health care personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation, or 4) the client commits or threatens to commit a crime either at the program or against any person who works for the program. Violation of the federal laws and regulation by a program is a crime. Suspected violations may be reported to appropriate authorities in accordance with Federal regulations. (42 USC section 290dd-22 and CFR 42 Part 2) Federal laws and regulation do not protect any information when child abuse or elder/ dependent adult abuse is suspected by program staff. (CA Penal Code Sections 11164- 11174.3 and § 368-368.5, CA Welfare & Institutions Code § 15630) Re-disclosure of protected health information is prohibited without specific written consent from the person to whom the information pertains or as otherwise permitted by law. Information disclosed pursuant to this authorization may be disclosed by the recipient and no longer be protected by State and Federal Law. I have the right to receive a copy of this authorization. Signature: Date: Print Name: Your relationship to the client: Self Parent/Legal Guardian