Attachment 9a - Authorization Requesting Release/receipt Of Information And/or Records - Riverside County Department Of Mental Health
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1Attachment 9A
Riverside County Department of Mental Health
Assessment and Consultation Team (ACT)
Authorization Requesting Release/Receipt of Information and/or Records
(Confidential Patient Information – W & I Code Sec. 5328)
Patient’s Name: ______________________________
Date of Birth:
___________________________
The Department of Public Social Services has arranged and is partially funding treatment services
for you as a part of a service plan through the Juvenile Court. As a part of this process, there is a
need to share information between your clinician/provider, the Riverside County Department of
Mental Health and the Riverside County Department of Public Social Services. This release of
information allows for this exchange of information. If you do not wish to sign this authorization,
you may still receive confidential services through your own resources. If desired, discuss possible
treatment resources with your clinician and, if you wish, with your DPSS social worker.
I, the undersigned, hereby authorize the following to release and exchange information. Please be
advised that this authorization allows disclosure as described above and the Riverside County
Department of Mental Health cannot be held liable for how this information is used by the
person/agency to whom the disclosure is made to and their safeguard practices.
Provider: _____________________________ Phone Number: ________________________
Riverside County Department of Mental Health Assessment & Consultation Team
Riverside County Department of Public Social Services
Information may be released with the knowledge that such contact discloses the fact that mental
health and/or chemical dependency services have been/are being provided.
This disclosure may include any of the following:
Assessment & Diagnosis
Consumer Care Plan and Discharge Summary
Psychological Testing
Medical, Neurological, Lab Tests, Medications
Progress Reports
This authorization becomes effective _______________. This authorization may be revoked by the
undersigned at any time, except to the extent that information has already been released. If not
revoked, it shall terminate one year from the date of authorization. You have the right to have a
copy of this Authorization upon request.
Date: ____________
Consumer Signature: ____________________________________
Authorization Revoked: _______________ Consumer Signature: _______________________
I refuse all release of information.
Date: ____________
Consumer Signature: ______________________________________
Confidential patient information. See California Welfare and Institutions Code Section 5328
Attachment 9A – ACT Release of Info
February 2012
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