This form is optional. Complete it only if you want me to share information with, or receive information from, another person or provider — for example to coordinate care with your psychiatrist or physician. Print and complete it by hand; do not email the completed form.
Client Information
Client name:
Date of birth: Phone:
I Authorize
Amber Faille, LCSW, Peaches Mindcare, 1000 Lincoln Rd, Ste H, PMB 38, Yuba City, CA 95991, (619) 535-8567
to release information to obtain information from both (exchange with):
Name / organization:
Relationship to client:
Phone: Fax / secure email:
Address:
Information to Be Disclosed
- Attendance / dates of service
- Diagnosis
- Treatment plan and goals
- Progress summary
- Medication information
- Discharge / termination summary
- Billing information
- Other:
The following categories receive special legal protection and will be disclosed only if you specifically initial them:
Substance use disorder treatment records (42 CFR Part 2)
HIV/AIDS-related information
Psychotherapy notes (note: an authorization for psychotherapy notes may not be combined with other authorizations; a separate form may be required)
Purpose of Disclosure
Coordination of care Continuity of treatment At my request
Other:
Expiration
This authorization expires on the earlier of the date or event below (if none is written, it expires one year from the date signed):
Date: or event:
Your Rights
- Right to revoke. You may revoke this authorization at any time by giving written notice to Amber Faille, LCSW. Revocation will not affect disclosures already made in reliance on this authorization.
- Treatment is not conditioned on signing. I will not refuse to treat you based on whether you sign this authorization.
- Redisclosure. Information disclosed under this authorization could be redisclosed by the recipient and may no longer be protected by federal privacy law. California law may still limit redisclosure.
- Copy. You are entitled to a copy of this signed authorization.
Signature
If signed by a personal representative rather than the client:
Description of representative’s authority to act for the client: