Release Of Information Marin Health And Human Services Page 2


Date of Birth
(print first name, middle initial, last name):
I understand my information may be disclosed and/or exchanged verbally or by telephone, fax and/or
secure email communication with representatives of the agencies listed on page one of this form.
The purpose for this authorization is to enable Public Health Nurses and other designated Marin
Family Connections providers to access my, or my child’s, health information from other providers to
assist, facilitate and coordinate the delivery of services for which I may be eligible.
This authorization is in effect for one year from the date of signature unless revoked in writing (see
below) and may be extended in writing beyond the first year by signing an addendum to this form. A
photocopy of this form shall be as valid as the original.
I may revoke (take back) this authorization at any time; I should submit my revocation request in
writing to the following address:
Marin Family Connections
Marin County Department of Health and Human Services
3240 Kerner Blvd., San Rafael, CA 94901
My revocation will take effect upon receipt, except to the extent that others have already acted in
reliance upon this authorization.
Some information disclosed pursuant to this authorization could be re-disclosed by the recipient.
Such re-disclosure is in some cases not protected by California law and may no longer be protected
by federal confidentiality law (HIPAA). I understand that my alcohol and/or drug treatment records
are protected under federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient
Records, 42 CFR Part 2, and cannot be re-disclosed without my written consent unless otherwise
provided for in the law.
I understand that I do not have to sign this authorization and that treatment, payment, enrollment or
eligibility for benefits will not be base on me signing or refusing to sign this authorization.
I understand that I have a right to receive a copy of this authorization.
Signature of Parent/Guardian ___________________________
Date ___________
Signature of child if > 12 years of age: _____________________
Date ___________
Witness ____________________________________________
Date ___________
DISTRIBUTION: Original copy of Authorization form to individual’s records, copy of form
provided to individual or his/her parent or guardian.
Marin Family Connections
- Marin County Department of Health and Human Services
HIPAA Form 03-01 (MFC)
3240 Kerner Blvd., San Rafael, CA 94901
Page 2 of 2
Phone: (415) 473-6008 / Fax: (415) 473-2211
REV 10.25.13


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