CalAIM Pathfinder

This form, when completed and signed by you, authorizes the use and/or disclosure of your protected health information. The information authorized for release may include information related to HIV/AIDS, mental health, and substance use, unless specified otherwise.

Person(s) or organization(s) authorized to make the disclosure:

any health care related agency or person providing information for the purpose of applying for the CalAIM CS for Assisted Living Transitions

Person(s) or organization(s) authorized to receive the information:

Connections Care Home Consultants, LLC

Specific information to be disclosed:

All medical records necessary for Community Supports (CS) application.

The information will be used for the following purpose:

To determine eligibility and arrange services for CS for Assisted Living Transitions.

This authorization expires:

One year from the date of signature.

My rights:

I understand that I may refuse to sign this authorization. My healthcare treatment is not dependent on my signing this form. I may revoke this authorization at any time by writing to the disclosing party, but it will not affect any actions taken before the revocation was received. A copy of this authorization is as valid as the original. I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy regulations.

Redisclosure:

I understand that the person(s) or organization(s) I am authorizing to receive my information may not be required to protect it under federal privacy laws (HIPAA). Therefore, the information may be re-disclosed without my consent.

HIPAA Authorization Form

Patient Information