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Drug/Alcohol Information ___________ (initial)
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Psychiatric Information ____________ (initial)
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Results of an HIV Blood Test ____________ (initial)
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Other: __________________________________________________________________________
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Exclusions: ______________________________________________________________________
The above information is being obtained to assist said authorized entities in evaluation of my claim for benefits
or damages. A copy or facsimile of this document shall be considered as effective and valid as the original.
REVOCATION: I understand that I have the right to revoke this authorization at any time. I understand that if
I revoke this Authorization I must do so in writing and present my written revocation to the health information
management department. I understand that revocation will not apply to my insurance company when the law
provides my insurer with the right to contest a claim under my policy.
DURATION: Unless otherwise revoked, this Authorization will expire on the following date, event or
condition: ______________________________________ OR in the absence of listed date, shall remain valid
for 1 year from date of signature.
The covered entity cannot require the patient to sign the authorization in order to receive treatment or payment
or to enroll or be eligible for benefits.
RE-DISCLOSURE: I understand that authorizing the disclosure of this health information is voluntary and that
I am entitled to a copy of this authorization and acknowledge receipt of a copy thereof. I can refuse to sign this
Authorization. I understand any disclosure of information carries with it the potential for an unauthorized re-
disclosure and the information may not be protected by federal confidentiality rules.
_____________________________________________________ ____________________
Signature of Patient or Legal Representative
Date
_____________________________________________________
If Signed by Legal Rep., Relationship to Patient (please print)
“Insurance Code 1879.2 – Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a
crime and may be subject to fines and confinement in state prison.” “For your protection California law requires the following to
appear on this form.”
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