Full Name
I authorize
to release Health information to We Care Daily Clinics.
Facility Address
Facility Phone Number
Facility Fax Number
The purpose of this release is for:
Continuity of care, Transfer, or Communication with Care Team
The Following records will be sent to We Care Daily Clinics:
OUD Treatment Summary including authorizations list, Medication List, and Problem List
The Following Health information is authorized to be exchanged:
Initial Screening, Diagnoses and Problem List, Biopsychosocial Assessment, Treatment Recommendations, Medical records, Test results, Recovery Plan and Progress, Treatment Recommendations and Referrals, Dosing History, and Face Sheet and Copy of ID
The following information will not be released:
Information pertaining to drug and alcohol abuse, diagnosis or treatment (42 C.F.R. §§2.34 and 2.35).
Information pertaining to mental health diagnosis or treatment (Welfare and Institutions Code §§5328, et seq.)
Release of HIV/AIDS test results (Health and Safety Code §120980(g)).
Patient Birthdate
Patient Phone Number
Email
Expiration of Authorization
If no date is indicated, the Authorization will expire 12 months after the date of signing this form. Unless otherwise revoked, this Authorization expires
(insert applicable date or event).
Print Name
Please Sign
Today Date
Relationship to Patient (Parent, Guardian, Conservator, Patient Representative)
NOTICE
We Care Daily Clinics (WCDC) and many other organizations and individuals such as physicians, hospitals and health plans are required by law to keep your health information confidential. If you have authorized the disclosure of your health information to someone who is not legally required to keep it confidential, it may no longer be protected by state or federal confidentiality laws.
YOUR RIGHTS This Authorization to release health information is voluntary. Treatment, payment, enrollment or eligibility for benefits may not be conditioned on signing this Authorization except in the following cases: (1) to conduct research-related treatment, (2) to obtain information in connection with eligibility or enrollment in a health plan, (3) to determine an entity’s obligation to pay a claim, or (4) to create health information to provide to a third party.
This Authorization may be revoked at any time. The revocation must be in writing, signed by you or your patient representative and delivered to Health Information Management Services. The revocation will take effect when WCDC receives it, except to the extent WCDC or others have already relied on it.
You are entitled to receive a copy of this Authorization.