Release Of Information Marin Health And Human Services
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1
2Marin Family Connections
Authorization Form
Name
Date of Birth
(print first name, middle initial, last name):
(month/day/year):
This authorization for the disclosure of medical records and information is being requested from you
to comply with the terms of HIPAA, 42 C.F.R., Part 2, the federal regulation that governs the
Confidentiality of Alcohol and Drug Abuse Patient Records. Confidentiality of Medical Information
Act, California Civil Code, Section 56, et seq., Welfare and Institutions Code, Sections 5328, et
seq., and Welfare and Institutions Code Sections 10850, et seq.
My confidentiality rights have been explained to me. Initials _____
I hereby authorize Marin Family Connections and/or any representatives of the
following agencies (expressly checked, initialed and dated) to use, disclose, release
and/or exchange my or my child’s medical, educational and/or mental health
information:
Initials
Date
Children and Family Services (CFS)
_____
______
Golden Gate Regional Center
_____
______
Matrix Parent Network and Resource Center
_____
______
Community Mental Health
_____
______
Primary Health Care Provider:_____________________________
_____
______
School(s):_____________________________________________
_____
______
Marin County Office of Education
_____
______
Head Start/Early Head Start
_____
______
Marin Childcare Council (MC3)
_____
______
Canal Alliance
_____
______
PEI Promotores
_____
______
Jewish Family and Children Services
_____
______
Family Service Agency
_____
______
Parent Service Project
_____
______
WIC
_____
______
Southern Marin Multidisciplinary Team
_____
______
Center for Domestic Peace (MAWS)
_____
______
Other: ______________________________________
_____
______
Marin Family Connections
- Marin County Department of Health and Human Services
HIPAA Form 03-01 (MFC)
3240 Kerner Blvd., San Rafael, CA 94901
Page 1 of 2
Phone: (415) 473-6008 / Fax: (415) 473-2211
REV 10.25.13
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