Department of Health Care Services – CBAS Assessment Information Release Form
AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION
I, ________________________, hereby authorize the Department of Health Care Services to release
(Name of Patient)
the materials used in my Community-Based Adult Services (CBAS) assessment materials to the
Adult Day Health Care (ADHC) center _______________________ that I am currently enrolled in.
(Name of ADHC center)
This information may include information on mental health, alcohol and/or drug treatment and
sexually transmitted diseases or HIV/AIDS. This information will only be used to help me get medical
care and services that I may need. All health information will be kept private and will not be released
unless authorized or required by law.
I understand that by signing this authorization:
I authorize the use or disclosure of my health information, including information on mental
health, alcohol or substance abuse and HIV/AIDS, as described above for the purpose listed.
This authorization is valid for one year from the date of signature.
I am signing this authorization voluntarily. I can withdraw this authorization at any time.
I understand that withdrawing my authorization will not be effective where the Department of
Health Care Services has already acted on my authorization in good faith.
I understand that my treatment, payment, and eligibility for Medi-Cal benefits will not be
affected if I do not sign this authorization.
I also understand that the ADHC cannot further disclose my information unless another
authorization is obtained from me or unless such disclosure is required or permitted by law.
____________________________ ____________________
Print Name of Beneficiary Medi-Cal Number
_______________________________________________ _________________________
Signature of Beneficiary or Legal Representative Date
Legal Authority:
___ Legal Guardian/Custodian. Attach a copy of proof of guardianship.
___ Healthcare Power of Attorney. Attach a copy of power of attorney.
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