Which dates of care the released records should cover. This is not how long the authorization lasts; that is section 6. Required: enter both dates, or check the box for all dates.
I understand: This information may be used by the person/provider/agency I authorize for medical treatment, consultation, billing, claims payment, or other purposes as I may direct. I have the right to revoke this authorization, in writing, at any time, except to the extent that any person or entity has already acted in reliance on it, or if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. My treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization. Information disclosed pursuant to this authorization may be re-disclosed by the recipient and may no longer be protected by federal or state law.
Substance use disorder treatment records: If the records I am authorizing include alcohol or drug treatment records protected by federal law (42 CFR Part 2), I understand that those records keep their federal protection after they are disclosed. The recipient may not use or disclose them, or testimony describing them, in any civil, criminal, administrative, or legislative proceeding against me unless I consent to that use or a court orders it under 42 CFR 2.64 or 2.65. If the recipient is a health care provider, health plan, or other HIPAA covered entity or business associate receiving the records for treatment, payment, or health care operations, it may re-disclose them only as the HIPAA rules permit, and never in a proceeding against me. Any other recipient may not re-disclose them unless my written consent expressly permits it or 42 CFR Part 2 otherwise allows. A general authorization for the release of medical information is not sufficient for that purpose. I understand that once these records are re-disclosed as permitted, they may no longer be protected by 42 CFR Part 2.
Copy of this authorization: I have the right to receive a copy of this signed authorization. After I submit it, this page will show my signed authorization with a button to print it or save it as a PDF. If I check the box below and enter my email address, CCBH's office will also email a copy to me. For more copies, on paper or digital, I can call (925) 289-9022 at any time.