AUTHORIZATION TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION – PARENT

I hereby authorize use or disclosure of the named individual’s health information

today’s Date:
CLIENT
Last Name:	First Name:	Initial:
Address:	City/State:	Zip Code:

Telephone Number:

SSN:

Date of Birth:

AKA’s:
THE FOLLOWING INDIVIDUAL OR ORGANIZATION IS AUTHORIZED TO MAKE THE DISCLOSURE.
Name or Entity: All Health and Education Providers, medical, dental, mental health and vision
Treatment Dates: ALL	Purpose of Request: pursuant to WIC 16010
THIS INFORMATION MAY BE DISCLOSED TO AND USED BY THE FOLLOWING ORGANIZATION:
Name of Entity: County of San Diego

Health and Human Services Agency

Child Welfare Services
Address

City/State:

Zip Code:

Telephone Number:	Date:
THE FOLLOWING INFORMATION IS TO BE DISCLOSED:
All records including, but not limited to:

History and Physical Examination

Discharge Summary

CWS Treatment Plans/Treatment Plan Updates (psychotherapy)

Medication Records

Interpretation of images: x-rays, sonograms, etc.

Laboratory results

Dental records

Psychiatric and psychological records including consultations

HIV/AIDS blood test results;

any/all references to those results

Physician Orders

Pharmacy records

Immunization Records

Nursing Notes

Drug/Alcohol Rehabilitation Records

All Education records
Sensitive Information: I understand that the information in my child’s record may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or infection with the Human Immunodeficiency Virus (HIV). It may also include information about behavioral or mental health services or treatment for alcohol and drug abuse.
Right to Revoke: I understand that I have the right to revoke this authorization at any time. I understand if I revoke this authorization I must do so in writing to the Social Worker. I understand that the revocation will not apply to information that has already been released based on this authorization.

Expiration: Unless otherwise revoked, this authorization will expire on the following date, event, or condition (parent to initial one):

_________ Upon termination of court jurisdiction or

_________ Upon termination of voluntary placement agreement.

If I do not specify an expiration date, event or condition, this authorization will expire in one (1) calendar year from the date it was signed.
Redisclosure: If I have authorized the disclosure of my child’s health information to someone who is not legally required to keep it confidential, I understand it may be redisclosed and no longer protected. California law generally prohibits recipients of my child’s health information from redisclosing such information except with my written authorization or as specifically required or permitted by law.
Other Rights: I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. However, for children who are dependents of the Juvenile Court, the Agency will request the Court to order the release this information.

I understand that Title 45 Code of Federal Regulations section 164.524 may provide me with the right to obtain from my child’s medical provider copies of the information to be used or disclosed pursuant to this authorization.

For children in protective custody: I understand that the information contained in my child’s health records is needed by HHSA for the purpose of determining the medical, developmental, dental and mental health status of my child to plan for his/her care, while not in my custody. I understand that HHSA may use this information to determine if my child should be made, or continued as a dependent of the Juvenile Court; whether my child should be removed from my custody and control, and if removed, to evaluate my progress in working to regain custody of my child.

I further understand that pursuant to the Welfare and Institutions Code and Superior Court Rules, my child’s health and education information will be shared with substitute caregivers, health and education providers, and officers of the Court or other parties in a dependency action in the Juvenile Court, or in subsequent proceedings to appoint a legal guardian or terminate the parental rights entirely.

I have received a copy of this authorization. ( Yes ( No

SIGNATURE OF INDIVIDUAL OR LEGAL REPRESENTATIVE
Signature:

Date:

Relationship to Individual:

County of San Diego	Health and Human Services Agency (HHSA)	Child Welfare Services

04-24A-P (6/13) L2	Page 1 of 2

Authorization to Use or Disclose PHI 04-24A-P

llee1

2014-06-20

shansen3

County of San Diego