WPC  ZNji@ !1 $CQ"&>睒(Z'wDS"W* 0h 0<) 0CerUJd 0~t#!UN %a Ng ^ i w@u 4  m $ \  `&Times New Roman<l:Default ParaXXX<:Footnote Ref86Body Text XXXS\  `&Times New RomanS        S\  `&Times New RomanSXXX'    0 .   kIA`2WP TypographicSymbols#|x7(Vm$     X:_XX XX:_XX X:_HP LaserJet 4,,,,0(9 Z6Times New Roman Regular X`Q4 ./01234E56D7au3yFilesU redisclosed  m!     XiXX XXFXX Xi  _    CONSENTTORELEASEMEDICAL,DENTAL,ANDPSYCHIATRIC  INFORMATIONTOATTORNEYANDOTHERS    X7  7ThisformorphotocopythereofshallauthorizetheBoardofPrisonTerms,CaliforniaYouthAuthority,CaliforniaDepartmentofCorrectionsandRehabilitation,allprivateandpublichealthcare,mentalhealthanddentalcareproviders,andtheiremployeesoragentstoreleaseanyattorneys,employees,and/orrepresentativesofSixthDistrictAppellateProgram,Inc.,anyandallofmymedical,dentalandpsychiatricrecordsandinformationfrom___________________tothepresentintheirpossession,andfurtherauthorizestheexaminationandcopyingofsaidrecordsandinformation.Thisauthorizationtorelease,examine,andcopyrecordsorinformationincludes,pursuanttoCaliforniaHealthandSafetyCodesection120980,theresultsofanHIVtestandanyrecordsorinformationpertainingtomycareandtreatmentresultingfromorsubsequenttoanysuchtests. X XSuchinformationmaybedisclosedbytheabovenamedattorneysortheiremployeesorrepresentativesforthepurposeofadvocatingonmybehalfwithrespecttoany1appeal,habeas12petition,2claim,complaint,orgrievanceImighthaveconcerningmy.crimesofconvictionand/or./thesentenceimposed,/0.sentence.0.or.3pertaini343n345ngto5.any.medicalconditionorconditionsofconfinement. H Thisauthorizationshallbeineffectandvalidforfiveyearsfromthedateofsignature,unlessitisearlierrevoked.IhavebeenadvisedthatIhavetherighttorevokethisauthorizationinwritingatanytime,andmaydosobysendingawrittenstatementwithmyname,signature,date,andCDCnumberto:SixthDistrictAppellateProgram,Inc.,100N.WinchesterBlvd.,Suite310,SantaClara,CA95050,statingthatIamrevokingmyauthorizationtodisclosetheprotectedhealthinformationidentifiedinthisauthorizationform. X XIunderstandthattheBoardofPrisonTerms,CaliforniaYouthAuthority,CaliforniaDepartmentofCorrectionsandRehabilitationandtheiremployeesoragentsmaynotconditiontreatment,payment,enrollmentoreligibilityforbenefitsonwhetherIsignthisauthorizationform.IfurtherunderstandthattheinformationdisclosedpursuanttothisauthorizationmayberedisclosedbytheabovenamedattorneysortheiremployeesorrepresentativesandthereforenolongerprotectedbythefederalprivacyruleregulationsundertheHealthInsurancePortabilityandAccountabilityAct(XXXXFAXFXXXHIPAAXXXXF@XFXXX). 0"   X XIhavebeenadvisedthatIhavearighttoreceiveacopyofthisauthorizationupondemand.6 %0!$ 6 $D #  XDate:___________________ h   __________________________________ %0!$  Signature  __________________________________PrintName  __________________________________CDCNumber