Authorization for Release of Mental Health

Milton Huang, M.D.
740 Front Street, suite 335
Santa Cruz, CA  95060

Patient Name: __________________________________________ Birthdate: __________________
Maiden or other name (if applicable)____________________________________________________
I request and authorize Dr. Milton Huang to release my mental health information to:
Name: ____________________________________________ Phone/Fax: ______________________
Address: __________________________________________________________________________
City, State: ______________________________________________ Zip code: __________________
This authorization is subject to the following restrictions (if any):
Treatment during the following time period or dates: All Other _________________________

The following will not be released unless you specifically authorize it by marking the relevant box:
I specifically authorize the release of information pertaining to drug and alcohol abuse.
I specifically authorize the release of HIV/AIDS test results.
I specifically authorize the release of genetic testing information.

Purpose(s) of this use/disclosure:
Disclosed at my request.
For treatment pruposes.
Other (state reason):________________________________________________________
Authorization expires: _________________________(date) If no date is indicated, the Authorization
will expire 12 months after the date of my signing this form.

- I understand that I may revoke this authorization at any time by making a written request to Dr.
Huang, except to the extent that action already has been taken in reliance on this authorization.
- I understand that my signing is voluntary, and Dr. Huang may not condition treatment or payment on
my signing this authorization. A third party may require this authorization to obtain information in
connection with eligibility or enrollment in a health plan, or to determine their obligation to pay a claim.
- I understand that information disclosed based on this authorization may be subject to redisclosure by the
recipient of this information, and no longer protected by federal privacy regulations.
- I understand I am entitled to receive a copy of this Authorization.

Signature (patient or authorized representative) _______________________________________
Date: _____________________
Relationship/authority (if signed by authorized representative): _________________________
Witness (only if patient unable to sign): ___________________________________________