- Practice
- Mindful Wellness Center
- Address
- 1420 Fillmore Street, Suite 310
- San Francisco, CA 94115
- Phone
- (415) 555-0182
- Fax
- (415) 555-0183 — Secure
- Practice
- Bay Area Behavioral Health
- Address
- 2899 Broadway, 2nd Floor
- Oakland, CA 94611
- Phone
- (510) 555-0461
- Fax
- (510) 555-0462 — Secure
The patient is transitioning psychiatric and therapeutic care to Dr. Michael Chen following her relocation to the East Bay. Records are being released for the sole purpose of continuity of clinical care, to preserve therapeutic context, avoid redundant assessment, and support informed medication management.
Disclosure is limited to the minimum necessary information for the receiving provider's clinical decision-making.
I understand that my records may contain information related to mental health treatment that is protected under HIPAA and California Civil Code §56.10. I specifically authorize the release of psychotherapy notes, which receive heightened protection.
I understand that the 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.
I may revoke this authorization at any time by submitting written notice to Dr. Sarah Kim, except to the extent that action has already been taken in reliance upon it.
My treatment, payment, enrollment, or eligibility for benefits is not conditioned on signing this authorization.