Form Ad 100a Authorization For Use And/or Disclosure Of Health Information Agency Adoption Program

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
AUTHORIZATION FOR USE AND/OR DISCLOSURE OF HEALTH INFORMATION
Agency Adoption Program
I, __________________________________________________ , the authorized agent of _________________________
CHILD’S NAME
AGENT’S NAME
born ____________________ , hereby authorize __________________________________________________ to disclose
DATE OF BIRTH
PHYSICIAN, HOSPITAL, CLINIC, SCHOOL, THERAPIST OR AGENCY
information regarding the above-name child’s medical history, mental or physical condition, care, or treatment to the
following:
■ ■
California Department of Social Services (CDSS)
■ ■
________________________________________ Licensed Adoption Agency
Address: _____________________________________________________________________
City, State, Zip Code: ___________________________________________________________
Telephone Number: (
)______________________________________________________
AGENT’S AUTHORIZATION TO RELEASE MEDICAL INFORMATION
Restrictions/Duration/Rights
My authorization limits the disclosure of the child’s information to the above agency for the purposes of adoption planning.
This authoirzation is limited to the following types of medical information:
■ ■
■ ■
Medical Information and History
Psycho-Social Information and History
■ ■
■ ■
Test or Examination Results
Labor & Delivery
■ ■
Other Information and/or Explanation: ______________________________________________________________
_____________________________________________________________________________________________
I authorize the release of the specified information from the child’s medical records.
●
I understand information disclosed pursuant to this authoirzation may be re-disclosed by the recipient and no longer
●
protected by federal confidentiality laws. However, use and redisclosure of the information are subject to the
requirements of Family Code Section 9200 et seq. and Title 22 California Code of Regulations Section 35127.1 et seq.
and Section 35049 et seq.
This authorization may be revocked at any time. My revocation will be effective upon receipt, but will have no impact on
●
uses or disclosures made while my authorization was valid.
This authorization will become effective immediately and will expire one year from the date of signature.
●
A photocopy of this release is as effective as the original.
●
I understand that I have a right to receive a copy of this authorization.
●
■ ■
The above-name child is a dependent of the _____________________________ County Juvenile court.
■ ■
The above-name child is in the custody of ________________________________ Adoption Agency for the purposes
of Adoption Planning.
SIGNATURE OF AUTHORIZED AGENCY:
DATE:
This document complies with the privacy requirements of the Health Insurance Portability and Accountability Act (HIPAA)
AD 100A (3/08)

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