Common use of INFORMATION TO BE RELEASED Clause in Contracts

INFORMATION TO BE RELEASED. This is a full disclosure authorization of health care information which includes health care maintenance records, and medical, surgical, sexually-transmitted disease, mental health, alcohol or other drug abuse care and treatment records, if any. This consent also authorizes the disclosure of HIV test results, if any. These records will be disclosed unless you specify information you wish excluded. Please initial below information you do not want released: NO Exclusions. Exclude: Exclude HIV test results INITIAL INITIAL Exclude Substance Abuse treatment information Exclude Mental Health treatment information _____ Exclude other information INITIAL This Authorization is effective immediately and will remain in effect for one year or until (date or event) Date Patient Signature SIGNATURE OF HOSPITAL STAFF WHEN REQUIRE Signature of Parent, Guardian, etc. Relationship EMPLOYEE NAME DATE LOCAL COURT FORM (MANDATORY) NEW, EFFECTIVE 11/1/19 MH-005 AUTHORIZATION TO DISCLOSE HEALTH INFORMATION Attachment 5 Docket No. (rpt. period every 30 days) Treatment Provider: Contra Costa County Superior Court’s Mental Health Diversion Program requires monthly reports of participant’s progress in treatment. A separate form must be completed for every 30 days of treatment. Please reference the treatment plan when you complete the entire form and provide to the participant or his/her attorney of record. Please submit at the end of each month. The last month’s report in the progress period must be submitted at least two days before the next court date (noted above).