SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN MATEO FAMILY COURT SERVICES 400 County Center, 6th Floor Redwood City, CA 94063-1668 Tel. (650) 363-4561 - Fax (650) 363-4966 www.sanmateocourt.org AUTHORIZATION FOR RELEASE OF RECORDS AND PROTECTED HEALTH INFORMATION Completion of this document authorizes the disclosure of health information and other records as set forth below, consistent with California and Federal law concerning the privacy of such information. Failure to provide all information requested may invalidate this authorization. To: _________________________________________________________________________________________________ Name: ________________________________________________________ Date of Birth: _______________________ Name: ________________________________________________________ Date of Birth: _______________________ I authorize the release and exchange of health and other information between Family Court Services and the above person / organization regarding myself and/or my minor children below: Name of Child: __________________________________ Date of Birth: ______________________ Name of Child: __________________________________ Date of Birth: ______________________ Name of Child: __________________________________ Date of Birth: ______________________ This authorization applies to the following health information and other records (select only one of the following): ‰ ‰ All health information pertaining to any medical history, mental or physical condition and treatment received, including drug / alcohol and / or HIV/AIDS, psychological, and / or psychiatric diagnostic evaluation. Only the following records or types of health information (including any dates): __________________________ This authorization also applies to the following information (select all that applies): ‰ Educational ‰ Investigative narratives from Child Protective Services I understand that the released records are to be used by the mediator to assist my family and myself in making recommendations to the Superior Court about the custody and / or visitation of my child(ren). I understand that I am responsible for any fees regarding this request. The records may be released in writing and / or verbally, as requested by Family Court Services. This authorization shall be valid for a one-year period from the date signed, unless consent is withdrawn in writing. RESTRICTIONS California law prohibits the requestor from making further disclosure of my protected health information and other records unless the requestor obtains another authorization from me or unless such disclosure is specifically required or permitted by law. YOUR RIGHTS I may refuse to sign this authorization. I may inspect or obtain a copy of the protected health information and other records that I am being asked to disclose. I have a right to receive a copy of this authorization. I may revoke this authorization at any time. My revocation must be in writing, signed by me or on my behalf, and delivered to: Family Court Services, 400 County Center, 6th Fl. Redwood City, CA 94063-1668. My revocation will be effective upon receipt, but will not be effective to the extent that the requestor or others have acted in reliance upon this authorization. Signature: _______________________________________________ Person Authorizing Release Signature: _______________________________________________ Person Authorizing Release A Superior Court hearing ( _______________________ Relationship Date _______________________ Relationship ) has been set for: _____________________________ _______________ _______________ Date ( ) has not been set. We would appreciate having the records / information by: _____________________________________________________ If any fees regarding this request should arise, please inform Family Court Services prior to sending the requested information. *** Print Name: ________________________________ Signature: ____________________________ Family Court Services Mediator Rev.: 6-18-10 / ce _________________ Date American LegalNet, Inc. www.FormsWorkFlow.com