645 Authorization to Request Release of Information

OBTAIN FROM: (Who is releasing information?) RELEASE TO: (Who is receiving information?)

_________________________________________________
________________________________________________
Name Name
_________________________________________
________________________________________
Address Address
_________________________________________
________________________________________
SPECIFIC INFORMATION REQUESTED: For The Following Dates: _____________________________________

X☐ Final Summary X☐ Psychiatric Assessment ☐x History & Physical Exam

X☐ Progress Notes ☐x Psycho-social Assessment ☐ xComp Exam or Observation Report

X☐ Physician’s Orders ☐ Educational Assessments ☐ Operative Report

☐ Lab/Path Results ☐ Medical/Surgical Final Summary ☐ EKG Report ☐ EEG Report

X
☐ Disposition Committee Notes X☐ Dental Report ☐x Drug/Alcohol Treatment

☐ Other psych order of Heather vamenzuelaphdstudentgrad jd master lkm master attorney luc psychologist and health law lic a d
itrnessand lic mediation and refetal order evaluation orders hold and legalholds and mental health hold on list of cult leaders of me and
Mexican mafia and cia executions of Las Vegas mafia informant of me my wedding and life for 20 yearssabotageand anti hate crime units
wadc ofeminemspossee and of thehollywood Alist or mafiaset upsofgov in Colorado authorities or Jessica Martinez and evaluation of head
otfrankdaniels cult leaders arrest and of mob main controllers and cults my friends did for me from Delta orbyhollywood alist of
kobebryants planecrash and fishy deaths investigated and suicide of amnanicole Smith and myself recordsrequestifrescuedfrom Justin
Edwards bypsychologist in mob with him is suicide in anybody if notcontrolledabdmaintained correctly and hiscia excutionsand of set upby
jenniferlopezto testify forhillaty Clinton andforcia excutions andusgov investigations about and Mex mafia of main controllers of Alicia
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allcontracthit man forhire setupsby shugknighttirnedthemintofbiamd murdered dead and witnesses dead guy and Jeri
ownergentlemamsclub and sennishoffand Anna Nicole hughhefner or Bob penthouse owner of magazine owners nowlarryflynt
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oralso Mike Valdez andmexmob Informant ofjustin in mob of my self and Alicia classi turned infor premeditated murder onme and much
less Jessica Martinez and judicial misconduct is what Michelle ishigjesanehaviorhealth priblem at this point or Jim orpam Lee Anderson
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dhillaty Clinton when is proofof burdenon meisheatherslife heather kids and family is not their buisness or what ismuke valdezthinking
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forensics informants cedtigationsformy own homicide for forcrced sucide iswhyiof playboy mansion hollywood Alist and federal indictment
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mexmob afederal statewitness against hersetup on Mex mafia a d again at cwmh andthefbii fkrmantofgra dju cyion andheadqisryershelping
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statefor jessucamaryinez and Michelle hughesabout a d searchwarramts attached on Justin edwardsfrom my lawfirm and for floridamafia
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murdered what they needcharged___forifheathernot rescuedsndmarriedin Las Vegas mafiaor mexmob of gj co ofhollywood fbi forensics
special circumstances of ciaheadquartersentertainmentliasionandexcutivecelebroty hollywoodslist isheather rvalrnzuela of Hollywood
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_______________________________________________________________________________________

THE INFORMATION ABOVE IS TO BE USED FOR:

X☐ Continuity of Care X☐ At the Request of the Individual

645 Authorization to Request Release of Information

X☐ Legal Purposes ☐x Other (specify)____No correspondence qhats goung in or what he rhonksisgoung on or

whats wring?_____case #19cv000562 feferal lawsuit against alicua classi and condide.tial.u fkrmantcase fbi.gk coor wpp case westbrook
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realkyput me tmrlugh over 20 ueats 20 to es wlrse rhan javy ses flralixia clasdi reystaningiktsees by staye.on her from.jystin edwards a.d
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.HDav_____m______________________________

NOTICE TO RECIPIENTS OF DRUG AND ALCOHOL TREATMENT PROGRAM INFORMATION

This information has been disclosed to you from records protected by Federal Law (42 CFR, Part 2). The Federal rules prohibit you from
making any further disclosure of this information unless authorization for the release of medical or other information is NOT sufficient for
this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

I understand that the information disclosed may contain testing or treatment information relating to mental health: drug and/or alcohol
abuse treatment, sexually transmitted disease (e.g., HIV/Aids virus).
I understand that CMHIP will not condition treatment, payment, or eligibility for benefits, if applicable, on their provision of an
authorization.

I understand that once the information is disclosed, the information is subject to redisclosure and may no longer be protected by the
federal privacy regulations.

I understand that this authorization will expire in one year from the date signed below.

I understand that this form may be revoked at any time providing the information has not already been disclosed. I may revoke this
authorization by notifying, in writing, the Medical Records Department.

I understand I can refuse to sign this authorization. I need not sign this form to assure treatment or services.
I will receive a copy of this signed authorization.
I ☐x do authorize the use of E-mail transmission of my Protected Health Information. INITIALS: _________________
______________________________________ ______________________________________
Printed Patient Name Date of Birth Printed Name of person authorized to sign for patient
______________________________________ ______________________________________
Patient Signature Date Signature of person authorized to sign for patient Date
______________________________________ ______________________________________
Address Relationship to patient Phone
______________________________________ ______________________________________
City State Zip Phone Address
______________________________________ ______________________________________
Witness Signature/Title Date City State Zip Code

PATIENT’S OR PERSONAL REPRESENTATIVE’S ACKNOWLEDGEMENT OF ACCESS TO MEDICAL RECORDS:

I hereby acknowledge that I/parent/guardian, or the designated representative, has inspected ☐ and/or have received ☐ photocopies of the medical records
of CMHIP inpatient treatment for the above named patient.

Signature: _____________________________________________________ Date:_________________________________

645 Authorization to Request Release of Information

AUTHORIZATION TO REQUEST/RELEASE Unit________

WRITTEN PATIENT DOCUMENTATION 645
Page 1 of 2
(11/9/16)

Attending Physician’s Acknowledgment of Patient’s Request for Access to Medical Records

I hereby acknowledge the request of the named-patient to ☐X inspect and/or x ☐ receive photocopies of the medical records of
hospitalization and/or outpatient treatment at Colorado Mental Health Institute at Pueblo. The records ☐ do not ☐x do contain
information relating to psychiatric problems or doctors’ notes which, if revealed to the patient, would have a significant negative
psychological impact upon him/her.
If access is denied, please complete Form 642, Explanation of Denied Access to Protected Health Information.

Signature of Attending Physician Date Time

A.M.

P.M.

Employee’s Acknowledgment of Information Given: ☐ Inspection of Record Date Inspected:____________________

COPIES MADE/DATES OF NUMBER OF COPIES GIVEN (SPECIFY DATES)

☐x Final Summary X Psychiatric xAssessment X☐ History & Physical Exam

☐ xProgress Notes X☐ Psycho-Social Assessment X☐ Comp Exam or Observation Report

X☐ Physician’s Orders X☐ Educational Assessments ☐ xOperative Report

X☐ Pathology Report X☐ Laboratory Report X ☐ Medical/Surgical Final Summary

X☐ Radiology Report X ☐ EKG Report ☐ Disposition Committee Notes

☐ xEEG Report X☐ Dental Record

X☐ Other Psych eval and order therapust appountmejtre sityatiob or mediation andor appt to clise oyt case mex m8b set yp in gearher a d
jtstin case nanagemrnt 9f fbi u firnant a d gj ci or geafqiarters 9fnhl a d las cefasmafia setup ilkwgal wpp case

NOTICE TO RECIPIENTS OF DRUG AND ALCOHOL TREATMENT PROGRAM INFORMATION

This information has been disclosed to you from records protected by Federal Law (42 CFR, Part 2). The Federal rules prohibit you from
making any further disclosure of this information unless authorization for the release of medical or other information is NOT sufficient for
this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.
I understand that the information disclosed may contain testing or treatment information relating to mental health: drug and/or alcohol
abuse treatment, sexually transmitted disease (e.g., HIV/Aids virus).

The Information above is to be used for:

Signature of Employee Releasing Information Date

Printed Name of Employee Releasing Information

 645 Authorization to Request Release of Information
REVOCATION SECTION
I do hereby request that this authorization to disclose health information of _____________________________________________
(Name of Patient)

signed by_________________________________________________ on _____________________________________________

(Enter name of Person Who Signed Authorization) (Enter Date of Signature)

be rescinded effective ____________________________________________________.

(Date/Time)
I understand that any action taken on this authorization prior to the rescinded date is legal and binding.
__________________________________ __________________________________
Printed Patient Name Printed Name of Person authorized to sign for patient

__Heather Valenzuels________________________________
__________________________Heather Valenzuela 07/29/2019________
Patient Signature Date Signature of Person authorized to sign for patient Date

__________________________ccase federal / lawsuit______

_________________________________
Address Relationship to patient Phone

__________________________________ _________________________________
City State Zip Phone Address

__________________________________ _________________________________
Witness Signature/Title Date City State Zip Code

Heather valenzuela Phd, llm Attorney AUTHORIZATION TO REQUEST/RELEASE Unit________

Luc psychotherapist and health lawlic
and mediation law and fitness
Unlv Hammond law
5025 nellis oasis lane #281 WRITTEN PATIENT DOCUMENTATION 645
las vegas nv 89115 Page 2 of 2
(11/9/16)
702-503-9165
Attorney #43475
Case #19cv000562
Lic Pacer 551875
Duns # 10375163
Fed tax id 83-1365316