STATE OF CALIFORNIA	DEPARTMENT OF REHABILITATION

CONSENT TO RELEASE MEDICAL INFORMATION	Page 1 of 3

DR 264A (REGS/Rev. 11/04)	See Page 3 for Important Notices

Individual/Facility Name & Address:

Consumer Full Name:

Consumer Address:

Name/Title of Person/Firm:

Social Security Number:

Date of Birth:

Nature of Treatment:

Date Last Treated:

Other Identifying Name:

Clinic or P.F. #:

CONSENT TO OBTAIN MEDICAL INFORMATION:

I authorize the above listed individual/facility to furnish to the Department of Rehabilitation (DOR) my records containing medical history, treatment, and diagnosed mental and physical condition, including disabilities such as drug, alcohol, and psychiatric, or the result of any HIV test performed. This information will be included in my case record and used to assist in the determination of eligibility and, if eligible, subsequent vocational rehabilitation services. The DOR may not disclose the information received without my signed consent for each disclosure unless the disclosure is specifically required or permitted by law. This consent shall remain valid for 30 days unless otherwise specified in Box A below.

Particularly requested is information from to regarding

my current general health status, including specific information pertaining to:

My signature below verifies that I have read the notifications on page 3 of this form and have received a copy of these notifications.

I understand that I have the right to receive a copy of this signed authorization.

Consumer Signature: (If minor or using "mark", see Box B and/or C)

	Date Signed:

Box A - Specified date, if other than 30 days:

Consumer Signature:

	Date Signed:

Box B - Parent or Guardian Signature (required for minor):

	Date Signed:

Box C - If unable to write his/her name, the consumer should enter an "X" or other mark above. Signatures of two (2) witnesses are required.	Witness Signature:

	Date Signed:

Witness Signature:

	Date Signed:

Send Information To:

Department of Rehabilitation

Rehabilitation Counselor:

Telephone:	Check if TTY:

DISTRIBUTION:	Original - Addressee	Copy - Case Record	Copy - Consumer

STATE OF CALIFORNIA	DEPARTMENT OF REHABILITATION

CONSENT TO RELEASE MEDICAL INFORMATION	Page 2 of 3

DR 264A (REGS/Rev. 11/04)	See Page 3 for Important Notices

Consumer Full Name:

CONSENT TO RELEASE MEDICAL INFORMATION:

I authorize the Department of Rehabilitation to release medical/dental/allied health information from my case record as shown below. This information may not be further disclosed without my signed consent. This consent shall remain valid for 30 days unless otherwise specified in Box A below.

Release Information to (Name & Address of Individual or Facility):

Information to be released is limited to:

My signature below verifies that I have read the notifications on page 3 of this form and have received a copy of these notifications.

I understand that I have the right to receive a copy of this signed authorization.

Consumer Signature: (If minor or using "mark", see Box B and/or C)

	Date Signed:

Box A - Specified date, if other than 30 days:

Consumer Signature:

	Date Signed:

Box B - Parent or Guardian Signature (required for minor):

	Date Signed:

Box C - If unable to write his/her name, the consumer should enter an "X" or other mark above. Signatures of two (2) witnesses are required.	Witness Signature:

	Date Signed:

Witness Signature:

	Date Signed:

Information Released By:

Department of Rehabilitation

Rehabilitation Counselor:

Telephone:	Check if TTY:

DISTRIBUTION:	Original - Addressee	Copy - Case Record	Copy - Consumer

STATE OF CALIFORNIA	DEPARTMENT OF REHABILITATION

CONSENT TO RELEASE MEDICAL INFORMATION	Page 3 of 3

DR 264A (REGS/Rev. 11/04)

NOTIFICATION TO CONSUMER

A consumer may refuse to allow the Department of Rehabilitation (DOR) to obtain medical information and may line out any form language and initial the change. If medical information is not obtained to substantiate a disability, it may result in a finding of ineligibility for services.

If the consumer wishes to disallow the DOR to release specific medical information contained in the consumer’s file to outside entities, s/he may refuse to sign the release.

NOTIFICATION OF THE

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996

You have the right to revoke this authorization by providing written notice to your Rehabilitation Counselor or the local office serving you. If you revoke the authorization it will not affect information already used or released before we received your written notice.

The federal Health Insurance Portability and Accountability law (HIPAA) may not protect information after it is released or provided to agencies not covered by that law. Even though the DOR does not fall under HIPAA legislation, the DOR does adhere to federal and state confidentiality requirements.

NOTIFICATION OF THE INFORMATION PRACTICES ACT OF 1977

This is confidential information from the records of the DOR. State and federal law and departmental regulations prohibit you from making any further disclosure of this information without the informed written consent of the person to whom this information pertains.

Under State law and departmental regulations, all information that you supply to the DOR is maintained in the consumer's file and is subject to inspection by the enclosed named individual and other authorized person(s) and agencies.

PRIVACY STATEMENT

The Information Practices Act of 1977 (Civil Code Section 1798.17) and the Federal Privacy Act (5 USC 552a(e)(3)) require this notice to be provided to individuals when collecting personal information. The information requested on this form, including the Social Security Number, is necessary to properly identify the individual to ensure that the DOR provides services to the correct individual. Failure to provide the information requested may result in delays in services. Department authority: Welfare & Institutions Code Sec. 19005, 19005.1, 19010.

STATEMENT OF NONDISCRIMINATION

The DOR affirmatively supports all federal and state civil rights laws and will not knowingly do business with any agency or entity which discriminates on the basis of ethnic group identification, national origin, race, color, creed, religion, sex, age, sexual orientation, physical or mental disability, medical condition, marital status or ancestry.

STATE OF CALIFORNIA

Lynda Bates

2009-08-11

RCademarti

Department of Rehabilitation