Authorization For Use Or Disclosure Of Information

Completion of this document authorizes the disclosure and/or use of individually identifiable information, as set forth below, consistent with California and Federal law concerning the privacy of such information. 

I, the undersigned, do hereby authorize the parties below to provide and exchange individually identifiable information (health, mental health, psychological, educational, HIV, substance abuse treatment, etc.) in verbal or written format from the above-named person's record: 

The disclosure of this information is required for evaluation to determine my eligibility to receive services and/or to provide services to me.


EXPIRATION:
This Authorization expires one year from date of signature.


RESTRICTIONS:
California law prohibits San Diego Regional Center (SDRC) from making further disclosure of my information unless SDRC obtains another authorization from me or unless such disclosure is specifically required or permitted by law.


YOUR RIGHTS:
I understand that I have the following rights with respect to this Authorization: 

I may revoke this authorization at any time. My revocation must he in writing, signed by me or on my behalf, and delivered to: Custodian of the Records, San Diego Regional Center, 4355 Ruffin Road, San Diego, CA 92123. 


My revocation will be effective upon receipt, but will not be effective to the extent that SDRC or others have acted in reliance upon this Authorization.


I have a right to receive a copy of this Authorization.


I do not have to sign this Authorization in order to receive services from San Diego Regional Center. 


I have the right to request a list of entities to which my information has been disclosed by the San Diego Regional Center. 

APPROVAL:

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SDRC #003 (Rev. 06/21) 

A Service of San Diego-Imperial Counties Developmental Services, Inc.

Serving Individuals with Developmental Disabilities 

Thanks for submitting the authorization form.