Form Mc 220 - Authorization For Release Of Information
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4State of California—Health and Human Services Agency
Department of Health Care Services
(Internal use
AUTHORIZATION FOR RELEASE
This box to be completed by SP-DDSD
only)
OF INFORMATION
Whose records are to be disclosed:
Name—First
Middle
Last
Social security number
Date of birth (mm/dd/yyyy)
PLEASE READ THE ENTIRE FORM BEFORE SIGNING.
I voluntarily authorize and request disclosure (including paper, oral, and electronic
interchange):
OF WHAT: All my medical records; also education records and other information related
to my ability to perform tasks. This includes specific permission to release:
1. All records and other information regarding my treatment, hospitalization, and outpatient
care for my impairment(s) including, and not limited to:
Psychological, psychiatric, or other mental impairment(s) (excludes “psychotherapy
notes” as defined in 45 CFR 164.501)
Drug abuse, alcoholism, or other substance abuse
Sickle cell anemia
Human immunodeficiency virus (HIV) infection (including acquired immunodeficiency
syndrome [AIDS] or tests for HIV) or sexually transmitted diseases
Genetic test results
2. Information about how my impairment(s) affects my ability to complete tasks and
activities of daily living or affects my ability to work.
3. Copies of educational tests or evaluations, including Individualized Educational
Programs, triennial assessments, psychological or speech evaluations, and any other
records that can help evaluate function; also teacher’s observations and evaluations.
4. Not only past information, but also information created within 12 months after the date
this authorization is signed.
FROM WHOM:
All medical sources (hospitals, clinics, physicians, psychologists, labs, etc.) including
mental health facilities
All educational sources (schools, teachers, records administrators, counselors, etc.)
Social workers/rehabilitation counselors
Consulting examiners used by State Programs–Disability Determination Service
Division (SP–DDSD)
Employers
Others who may know about my condition (family, neighbors, friends)
TO WHOM: The
California
Department
of
Social
Services
(CDSS)
or the
Department of Health Care
Services
(DHCS)
for
the purpose of
determining whether I qualify for disability benefits, including contract copy
DO NOT ALTER THIS FORM
Page 1 of 4
MC 220 14pt (04/08)
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