Authorization To Use Or Disclose Protected Health Information (Page 2 of 2) in pdf

Authorization To Use Or Disclose Protected Health Information Page 2

CANYON RIDGE HOSPITAL

AUTHORIZATION TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION

EXPIRATION

Unless, otherwise revoked, this Authorization expires _________________ (insert date). If no

date is indicated, it will expire upon its completion or 12 Months from date of signature, whichever

comes first.

MY RIGHTS

I understand the information in the Canyon Ridge Hospital health record relates to psychiatric and

mental health services and may also include information relating to AIDS, HIV, sexually

transmitted diseases, drug or alcohol treatment, drug or alcohol abuse and other abuse.

I may refuse to sign this authorization. My refusal will not affect my ability to obtain treatment or

payment or eligibility for benefits. I may inspect or obtain a copy of the health information that I am

being asked to allow the use or disclosure of. I have a right to receive a copy of this authorization.

California law prohibits the person receiving my health information from making further disclosure

of it unless another authorization for such disclosure is obtained from me or the disclosure is

specifically required or permitted by law. However, information disclosed pursuant to this

authorization could be redisclosed by the recipient. Such redisclosure is, in some cases, not

prohibited by California law and may no longer be protected by federal confidentiality law (HIPAA).

I may revoke this authorization at any time, but I must do so in writing and submit it to the

following address Medical Records, Canyon Ridge Hospital, 5353 G. Street, Chino, CA 91710. My

revocation will take effect upon receipt, except to the extent that others have acted in reliance

upon this authorization.

SIGNATURES AND ACCEPTANCE

Patient:

Signature:

Printed Name:

Date:

(Required)

Parent / Guardian / Legal Representative / Conservator of Patient:

(Law requires patients 13 to 17

years of age to sign for the release of their mental health records when requested by a parent/legal representative)

Signature:

Printed Name:

Relationship:

(Required)

Date:

(Required)

Witness:

Signature:

Printed Name:

5353 G. Street, Chino, CA 91710 | Tel: (909) 590-3700 x2060 | Fax: (909) 590-4038

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Authorization To Use Or Disclose Protected Health Information Page 2