Authorization to Release Patient Records

I specifically authorize the release of substance use disorder records protected under 42 CFR Part 2. I understand that the recipient is prohibited from making any further disclosure of this information unless further disclosure is expressly permitted by my written consent or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical information is NOT sufficient for this purpose.

I specifically authorize the release of HIV/AIDS test results and related information. I understand that under California Health & Safety Code § 120975, such disclosure requires my specific written authorization and that recipients are restricted in how they may further disclose this information.

I understand I have the right to revoke this authorization in writing at any time, except to the extent that the practice has already acted in reliance on it. To revoke, I must submit a written revocation to the practice.

I understand that information disclosed under this authorization may be redisclosed by the recipient and may no longer be protected by HIPAA. The practice has no control over how the recipient uses my information after release.

I understand the practice may charge a fee for copies of my records as permitted by California Health & Safety Code § 123110 (currently $0.25 per page for paper copies, $0.50 per page for copies from microfilm, plus reasonable clerical costs, subject to statutory caps). Copies sent directly to another treating provider for continued care are typically provided without charge. The practice will notify me of any applicable fee before processing my request, and I may decline to proceed if I do not wish to incur the fee.

I understand that signing this authorization is voluntary. The practice will not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this authorization (except where permitted by law).

I understand the practice will verify my identity before releasing records (typically by photo ID, security questions, or in-person verification). This protects me from fraudulent record requests.

I understand I have the right to receive a copy of this signed authorization. A copy will be provided to me automatically and is available on request at any time.

I understand this authorization meets the requirements of California Civil Code § 56.11. I have been provided this authorization in plain language, separated from other consents. I have the right to receive a copy of this signed authorization, and one will be provided to me on request.