give my consent to allow the Family Guidance and Therapy Center to share all information related to assessment and health treatment, including behavioral health treatment (sometimes called "Applied Behavioral Analysis" or "ABA") originated and maintained by the Family Guidance and Therapy Center allowed under Federal and State law with Partnership Health Plan.

I also allow the Medi-Cal Managed Care Health Plan to share this information with the Family Guidance and Therapy Center. Sharing this information helps my treatment. It also helps my treatment if I move to another Medi-Cal Managed Care Health Plan. Treatment information can include previous care, evaluation/tests, assessments, provider/therapy notes, provider orders, care records, care plan, medicines, and release notes. I know that my record may include info about sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or illness with the Human Immunodeficiency Virus (HIV It may also include information about behavioral or mental health services. Any alcohol and/or drug treatment records cannot be released unless I give written permission. This is due to federal rules (42 C.F.R. Part 2 and 45 C.F. R. pts. 160 & 164 There may be exceptions to this rule. The least amount of information needed should be released for evaluation and behavioral health treatment.

I will still be allowed to use the plan benefits if I do not sign the form. But, if I do not sign the form, it could take longer to get the care I need. And my plan would not be able to organize all of my care.

I know that sharing the info will help me to not have a break in care, care planning, and/or transfer of care. This consent form is valid for one (1) year from the date I sign it. I can choose to cancel it at any time.

 

• allow the use of my or my child's protected health and private information shown above for the reasons listed. this form is not required.

I know that:

• I will receive a copy of this form.
• I may cancel this agreement at any time. I can send a letter signed by me to the Family Guidance and Therapy Center where I have been receiving evaluation or treatment services. I can also send a letter to my Medi-Cal Managed Care Health Plan. If I cancel, the agreement will stop on the date the letter is received or the date listed in the letter, whichever is later. It will not affect information that has already been used or revealed.

This agreement is good for one (1) year from when I sign it or 60 days after the end of treatment, whichever is later.