Authorization for LA HLPP Referral

The following Authorization will permit LA HLPP staff and volunteers to share information regarding your matter with our legal and social service partners.

I authorize the Los Angeles HIV Law and Policy Project (LA HLPP) or any other representative of LA HLPP at 385 Charles E. Young Drive East, Los Angeles, CA 90095, (310)794-7367, to release any and all knowledge, information or records regarding my intake regarding the following: 

 

[BRIEF DESCRIPTION OF MATTER]

 

I understand that for LA HLPP to place my matter with referral partners including legal services organizations and volunteer attorneys, LA HLPP must provide referral partners with specific information about me and my matter. Since LA HLPP only provides services to people living with HIV, the potential partnering organization and/or volunteer attorney will know that I am living with HIV. Additional information that may be shared includes the following:

• My name, birth date, and address

• The other parties’ names and addresses

• A brief description of the facts

• Details about my medical condition

 

I authorize the release of this information by LA HLPP to potential legal service providers and/or volunteer attorneys. I waive any attorney-client privilege to this information to the extent required. This information will ONLY be used to determine whether an LA HLPP referral partner can/cannot provide legal representation for the matter listed above. This release shall expire one year from the date of execution unless otherwise revoked by me.  A photo or faxed copy shall be as effective as the original.

 

To the extent I am authorizing a covered entity to disclose protected health information: I understand that I may revoke this authorization at any time and that I must do so in writing. I understand that I may refuse to sign this authorization, and, as a result, I may not be denied treatment or benefits because I have refused to sign the authorization. I understand that information disclosed based on this authorization may be re-disclosed by the entity or the person who receives the information. Once disclosed, it is possible that the information will no longer be protected under federal medical privacy law. I understand that a recipient of information in California may not further disclose information about me without additional authorization unless disclosure is required/permitted by law. I understand that a recipient of information in California may not further disclose information about me without additional authorization unless disclosure is required/permitted by law. I understand that I may inspect or copy the protected health information to be used or disclosed subject to the discretion of my provider, and based on my right to access to my protected health information, pursuant to HIPAA, and that I may receive a copy of this authorization.  If the information being released involves treatment for alcohol or substance use, it is further protected by federal law (42 C.F.R. Part 2) and will not be shared with anyone else unless you sign a separate form.