Mga Madalas Itanong (FAQs)

• Mga Kasosyo sa Pangangalaga
• Mga kliyente

FAQ Updates

These FAQs have been updated as of July 1, 2026. They will continue to be updated as the ASCMI Initiative continues to mature.

Mga Kasosyo sa Pangangalaga

Layunin

The purpose of these FAQs is to provide information for providers’ reference as they administer the Authorization to Share Confidential Member Information (ASCMI) Form to their Clients. They contain further detail on the purpose of the Form, structure, and permissible disclosures. The Department of Health Care Services (DHCS) has additionally developed a set of Client-facing FAQs on the Form that you may share with your Clients.

Pangkalahatang Impormasyon Tungkol sa ASCMI

1. What is the ASCMI Initiative?

The ASCMI Initiative is a statewide effort to promote and standardize the exchange of Clients’ protected information, including certain physical health, behavioral health, and social services information, between Care Partners (e.g., providers, health plans, county agencies, social services organizations, etc.). Care Partners may use the ASCMI Form to obtain their Clients’ consent to share their information for the purposes of coordinating their care, delivering treatment, or payment and health care operations (see FAQ #2).

The state is also developing an electronic consent management portal to store completed ASCMI Forms. DHCS envisions Care Partners will be able to access the portal to verify if their Clients have a consent record on file before presenting them with the Form. Concurrently, DHCS is exploring methods to support Care Partners with facilitating health and social services information exchange. Additional details on the design and launch of the consent management portal are forthcoming.

2. What is the ASCMI Form?

The ASCMI Form is a release of information form you can use to request your Clients’ consent to share their information with providers that are also a part of their care team. You may need to exchange your Clients’ information to:

• I-coordinate ang kanilang pangangalaga.
• Bigyan sila ng medikal, dental, kalusugang pangkaisipan, at paggamot at mga serbisyong may karamdaman sa paggamit ng sangkap.
• Kumuha ng bayad para sa paggamot at mga serbisyong ibinibigay mo.
• Tulungan silang ikonekta sa mga programa, serbisyo, at mapagkukunan.
• Sumusunod ang Form sa mga kinakailangan sa form ng awtorisasyon sa ilalim ng mga nauugnay na batas sa pagbabahagi ng data ng pederal at estado (tingnan ang FAQ #11-12) at mga detalye kung aling mga uri ng impormasyon ang nangangailangan ng pahintulot upang magbahagi ng data.

3. Why are there two versions of the Form? What are the differences between the AB 133 and Non-AB 133 versions of the Form?

Assembly Bill (AB) 133 (2021) is a California law that allows Care Partners to share some of their Clients’ information without their signed consent in order to provide them with services or coordinate their care. The data sharing rules of AB 133 (2021) apply to Clients enrolled in Medi-Cal managed care, receiving behavioral health services under Medi-Cal, or receiving pre-release services through the Justice-Involved Reentry Initiative. If these conditions do not apply to your Client, they should sign the Non-AB 133 Version. The AB 133 and Non-AB 133 versions differ in several ways, which are outlined in multiple FAQs in this document.

4. How does the Form differ from additional consent to release information (ROI) forms (e.g., Homeless Management Information System (HMIS) Release of Information Form)?

The ASCMI Form is a standardized consent form designed specifically for care coordination across sectors while other ROI forms are typically traditional, entity-specific releases not built for coordinated, multi-party data sharing in alignment with HIPAA, 42 CFR Part 2, and other state data sharing laws.

With regard to a HMIS ROI form, generally, no individual consent is needed to disclose housing status from HMIS, as long as such data sharing is permissible in the Continuum of Care (CoC) Notices of Privacy Practices (NPPs). If housing data is originating from a CoC’s HMIS, and the CoC NPP does not expressly permit data sharing for the purposes of care coordination, the ASCMI Form can be used by a CoC to capture the necessary Client consent. It is possible that other consent to release information forms are specific to a population or service. Consult your organization’s counsel and/or privacy office to determine whether consent is needed and the appropriate release of information form to use. Question 12 includes more details about U.S. Department of Housing and Urban Development HMIS laws.

5. If my organization has an existing consent to release information form, do I need to use the ASCMI Form? Do Individuals need to sign both?

For use cases that are not covered under the current ASCMI Form 2.0, counties may use other consent to release information forms. The ASCMI form does not currently support child welfare data sharing, data sharing under FERPA, or sharing protected reproductive health data. Consult your organization’s counsel and/or privacy office to determine if the Form (AB 133 or Non-AB 133 Version) can replace or be used alongside an existing consent to release information form.

Beginning January 1, 2027, Mental Health Plans (MHPs), Drug Medi-Cal Organized Delivery Systems (DMC-ODS), Drug Medi-Cal (DMC) State Plan Counties, and Managed Care Plans (MCPs) are required to use the ASCMI Form as their standardized consent form (see BHIN 26-013 and APL 26-004 for additional details on this requirement). This requirement extends to any Care Partner contracted with these entities. For all other sectors, DHCS highly recommends those Care Partners use the ASCMI Form as their standard consent form.

6. Is the Form a data sharing agreement?

Hindi. Ang Form ay nagdodokumento ng pahintulot ng Kliyente na magbahagi o hindi magbahagi ng mga partikular na uri ng impormasyon na nakalista sa Seksyon 2.3 ng Form (tingnan ang FAQ #9). Ang Form ay hindi nagtatatag ng kasunduan sa pagbabahagi ng data sa pagitan ng mga organisasyon ng Care Partner.

7. What is the benefit of using the Form?

Maraming benepisyo ang paggamit ng Form, kabilang ang:

• Ito ay nakasulat sa payak na wika, sa antas ng pagbabasa na magagamit ng mga indibidwal na may edukasyon sa gitnang paaralan o mas mataas.
• Binabawasan nito ang administratibong pasanin, dahil ang karaniwang Form ay maaaring gamitin sa maraming sektor. Maaaring pahintulutan ng iyong Kliyente ang pagbabahagi ng maraming uri ng impormasyon sa kanilang pangkat ng pangangalaga alinsunod sa mga nauugnay na batas sa pagbabahagi ng data at privacy.
• Naaayon ito sa mga pagbabago sa estado at pederal sa pagbabahagi ng data at mga batas sa privacy, gaya ng na-update na 2024 42 CFR Part 2 (“Bahagi 2”) na mga regulasyon.

8. How long is my Client’s consent active? When does their consent expire?

Sa pangkalahatan, ang pahintulot ay mawawalan ng bisa isang taon mula sa petsa ng pagpirma para sa parehong mga form.

Gayunpaman, kung ang iyong kliyente ay 17, ang kanyang pahintulot ay tatagal lamang hanggang sa siya ay maging 18 o hanggang sa magbago ang kanyang pangangalaga, na maaaring wala pang isang taon.

Gayunpaman, pinananatili ng mga Kliyente o kanilang magulang, tagapag-alaga, o legal na kinatawan ang karapatang bawiin ang kanilang pahintulot o baguhin ang kanilang mga kagustuhan sa pagpapahintulot bago ito mag-expire kung pipiliin nila.

9. What types of information does the Form authorize to be shared?

Ang AB 133 na Bersyon ay maaaring gamitin upang makakuha ng pahintulot para sa pagbabahagi ng mga sumusunod na uri ng impormasyon:

• Impormasyon sa Karamdaman sa Paggamit ng Substance na protektado ng Bahagi 2 (hal., mga pagsusuri, mga detalye ng reseta, mga talaan ng paggamot).
• Housing information that is not included in a Continuum of Care’s Notices of Privacy Practices (e.g., housing assessment completed by Coordinated Entry). See question 4 for more details.

Ang Di-AB 133 na Bersyon ay maaaring gamitin upang makakuha ng pahintulot para sa pagbabahagi ng mga sumusunod na uri ng impormasyon:

• Impormasyon sa Karamdaman sa Paggamit ng Substance na protektado ng Bahagi 2 (hal., mga pagsusuri, mga detalye ng reseta, mga talaan ng paggamot).
• Impormasyon sa Substance Use Disorder na hindi protektado ng 42 CFR Part 2.
• Housing information that is not included in a Continuum of Care’s Notices of Privacy Practices (e.g., housing assessment completed by Coordinated Entry). See question 4 for more details.
• Impormasyon sa Kalusugan ng Pag-iisip (hal., mga rekord ng paggamot, mga pagtatasa).
• Impormasyon sa Intelektwal at Developmental na Kapansanan (hal., mga rekord ng serbisyo sa pag-unlad, Plano ng Indibidwal na Programa, pagtatasa ng pagiging karapat-dapat sa Regional Center).
• HIV Test Results (note – when an ASCMI Form is collected digitally through the Consent Management Portal (CMP), HIV test results will not be included, as Health & Safety Code § 120980(g)requires a new authorization for each HIV test result disclosure and the CMP is unable to track whether disclosures are made at time of querying for a Client’s consent preferences. Instead, providers will need to rely on localized policies and processes to ensure compliance with the regulation. See question 42 for more information).
• Mga Resulta ng Genetic Test.

10. Can my Client choose what information they want to share?

Yes, they can choose using the checkboxes in Section 2.3: “Your Consent.” The checkboxes represent their consent preferences for each of the information types that require their special permission to share.

If they select “Yes” for any of these information types, you can share that information with their other Care Partners to coordinate their care.

If they select “No,” you cannot share that information with their other Care Partners.

11. Does the Form restrict the sharing of other types of health and social services information?

No. The Form is intended to obtain consent for data sharing when required by federal or state law. Regardless of whether a Client signs the Form, Care Partners may continue to share some physical health, behavioral health, and social services information for purposes permitted under the Health Insurance Portability and Accountability Act (HIPAA), including treatment, payment, and health care operations. Under HIPAA, information can also be used for other limited purposes, such as research or public health activities.

You may refer to the Data Sharing Authorization Guidance for an overview of data sharing permitted under AB 133 (2021). Care Partners that serve Clients to whom AB 133 (2021) does not apply may refer to the State Health Information Guidance developed by the California Health and Human Services Agency (CalHHS) for additional information.

12. What privacy laws or standards apply to the special permissions in Section 2.1?

Laws or standards that apply to the special permissions in both AB 133 and Non-AB 133 Versions include the following:
42 C.F.R. Part 2, which is a federal regulation intended to protect the confidentiality of substance use disorder treatment information and to ensure that such information is not used against an individual in criminal, child custody, divorce, employment proceedings, or other proceedings against the individual. For more info, see the full federal regulation and the HHS Fact Sheet.

Homeless Management Information System (HMIS) data entry and exchange. Housing organizations and CoCs that are regulated by U.S. Department of Housing and Urban Development (HUD) that record, use, or process data in HMIS are required to document the reasons for collecting Clients’ information in their Privacy Notice. Uses and disclosures that are not included in the Privacy Notice require written consent. For more info, see a model Privacy Notice and the HMIS requirements developed by the U.S. Department of Housing and Urban Development (HUD). See FAQ #4 for more information on when consent is needed to disclose housing information.

AB 133 (2021) limits the applicability of certain privacy laws to enable Care Partners to exchange information without patient consent for the purposes of coordinating care for certain populations. See FAQ #3 for a list of populations that AB 133 (2021) applies to. You may refer to Section 3 of the CalAIM Data Sharing Authorization Guidance (DSAG) for an overview of data sharing permitted under AB 133 (2021).

Kasama sa mga batas na nalalapat lamang sa Di-AB 133 na Bersyon ang sumusunod:

• California Confidentiality of Medical Information Act (CMIA).
• Kodigo sa Kalusugan at Kaligtasan ng California Seksyon 11845.5.
• California Lanterman-Petris-Short Act.

Note that some of these laws may have additional consent requirements, and you should consult with your counsel and/or privacy office for a full understanding of them. For example, the Lanterman-Petris-Short Act requires the approval of the physician and surgeon, licensed psychologist, social worker with a master’s degree in social work, licensed marriage and family therapist, or licensed professional clinical counselor who is in charge of the patient when disclosing covered information to a person the patient has designated.

13. Do I have access to all information that my Client has consented to sharing on the Form?

No. You will have access to the minimum necessary information that you need in order to provide your Clients with care or services. You will not have access to information they have consented to sharing unless it is necessary for the care or services you seek to provide. Care Partners are expected to share and request information in accordance with the minimum necessary standards under the HIPAA Privacy Rule.

14. If I receive permission (via the Form) to access my Client’s information, can I redisclose to additional Care Partners in the future?

Ang mga pahintulot sa muling paghahayag ay nag-iiba ayon sa uri ng impormasyon at depende sa kung anong uri ka ng entity. Halimbawa, kung isa kang entity na sakop ng HIPAA o business associate, maaari mong muling ibunyag ang lahat ng uri ng impormasyong natatanggap mo alinsunod sa ASCMI Form, kabilang ang impormasyon ng Part 2, hangga't ginagawa mo ito alinsunod sa HIPAA (hal, para sa mga layunin ng paggamot, pagbabayad, at koordinasyon ng pangangalaga). Kung ikaw ay hindi isang sakop na entity o business associate, ang mga layunin kung saan maaari mong muling ibunyag ay mas limitado. Ang Mga Kasosyo sa Pangangalaga ay dapat sumangguni sa kanilang mga opisyal sa pagkapribado na may mga tanong tungkol sa muling paghahayag. Tingnan ang mga karagdagang pagsasaalang-alang sa muling paghahayag sa FAQ #12.

15. Can a HIPAA covered entity use the ASCMI Form to share protected heath information (PHI) with non-HIPAA covered entities?

Yes, the ASCMI Form can be used to authorize disclosure of protected information to non-covered entities.

In most cases, HIPAA permits a covered entity to disclose protected health information (PHI) without individual authorization for purposes of treatment, payment, or health care operations, even when the recipient is not a HIPAA-covered entity (45 C.F.R. Section 164.506(c)(1)).

However, in some instances, consent is needed to share PHI

• Certain medical (e.g., genetic testing and HIV testing)
• Mental health information protected by Lanterman-Petris-Short Act (LPSA)
• Substance use disorder (SUD) status and treatment information
• Impormasyon sa Seguro sa Kalusugan
• Housing and income status, history, and supports that originate from a Continuum of Care when not otherwise permitted by that Continuum of Care’s Notice of Privacy Practices
• Limited criminal legal information, including booking data, dates and location of incarceration, and parole status).

In these cases, Care Partners can use the ASCMI Form to capture a Client’s consent preferences to authorize such disclosure.

Pangangasiwa sa ASCMI Form

16. Which version of the Form should my Client sign?

The AB 133 Form can be used for any Medi-Cal Managed Care Member currently receiving services under CalAIM (e.g., Medi-Cal behavioral health services, Enhanced Care Management (ECM), Community Supports, Justice-Involved Reentry Initiative) (See W&I Code Section 14184.102(a) outlining the CalAIM components). AB 133 (2021) does not apply to Medi-Cal Fee-for-Service, aside from a discrete set of behavioral health services (See W&I Code Section 14184.402(b)).

The non-AB 133 Form can be used by anyone—including Medi-Cal Members receiving CalAIM services—either upon their request or when their providers choose to use the non-AB 133 Form.

17. Is there any guidance for implementing the Form? When should I ask my Client to sign the Form?

Ipinagpapaliban ng DHCS ang Mga Kasosyo sa Pangangalaga sa pagtukoy kung kailan ibibigay ang Form batay sa daloy ng trabaho ng iyong organisasyon at sa partikular na konteksto kung saan ka nagbibigay ng mga serbisyo sa isang indibidwal. Sa ilang mga kaso, maaaring pangasiwaan ng Mga Kasosyo sa Pangangalaga ang Form sa punto ng paggamit/pagpapatala o habang nagbibigay ng mga serbisyo sa isang Kliyente. Maaaring pangasiwaan ng Iba pang Mga Kasosyo sa Pangangalaga ang Form kapag ang data ng Kliyente ay dapat ibahagi.

18. Can I administer the Form during a telehealth visit?

Yes. The ASCMI Form can be administered during a telehealth visit. It requires either a “wet” handwritten signature on a paper copy or an electronic signature. An electronic signature can include an oral and timestamped recording that meets other requirements of electronic signature laws.

You may send your Client an electronic copy to sign or read the ASCMI Form to them and record their oral consent.

19. Can I modify the Form by amending sections that are not relevant to the services I provide?

Care Partners may supplement the Form with additional details regarding the services they provide but cannot strike/amend any sections.

20. Is there any benefit to presenting my Client with the Form if none of the “special permissions” apply to them?

Oo. Kung ang "mga espesyal na pahintulot" ay nalalapat sa iyong Kliyente sa hinaharap, ang pagkuha ng kanilang pahintulot kapag pinangangasiwaan ang Form ay maaaring magpapahintulot sa iyo na palitan ang kanilang impormasyon kapag kinakailangan.

21. Should my Client still sign the Form, even if they do not grant permission to share any information types that require their special permission?

Oo. Dapat mo pa ring idokumento ang mga kagustuhan sa pagpapahintulot ng iyong Kliyente, kahit na tinanggihan nila ang pagsisiwalat ng anumang data na pinahintulutan ng Form sa pamamagitan ng pagpili sa checkbox na “Hindi”. Iniiwasan nito ang muling paghiling ng pahintulot ng iyong Kliyente na ibahagi ang kanilang data at itala ang kanilang kahilingan na huwag ibahagi ang data na iyon.

Gayunpaman, ang pagpirma sa Form ay opsyonal, at maaaring tanggihan ng iyong Kliyente na kumpletuhin ang Form. Dapat ipabatid ng Mga Kasosyo sa Pangangalaga ang mga Kliyente na ang ilan sa kanilang data ay maaari pa ring ibahagi (tingnan ang FAQ #11) at maaari silang hilingin muli na kumpletuhin ang Form sa hinaharap.

22. What happens if my Client does not sign the ASCMI Form?

Signing the Form is optional. If your Client has questions about the Form, you may direct them to the Client-Facing ASCMI Form FAQs.

Sumangguni sa seksyong Mga FAQ ng Behavioral Health Care Partners sa dokumentong ito para sa karagdagang patnubay kung isa kang Part 2 Substance Use Disorder Provider at ang iyong Kliyente ay tumanggi na pumirma sa ASCMI Form.

23. Does my Client need to sign the ASCMI Form to receive treatment?

No, Clients do not need to sign the ASCMI Form to receive treatment. The ASCMI Form authorizes disclosure of information and does not authorize treatment. For some services, consent is needed to share protected information for payment purposes (e.g., substance use treatment). In these cases, if the Client does not sign the ASCMI Form, they can still receive treatment, but their provider may not be able to submit a claim for the service to their insurance company, unless they sign a separate consent form for payment purposes only.

24. Can my Client specify which provider types are authorized to receive their data via the ASCMI Form?

The ASCMI Form does not allow Clients to limit disclosures to specific provider types. The Form is intentionally structured as a broad treatment, payment, and health care operations (TPO) authorization – in accordance with applicable law, including the updated 42 CFR Part 2 Final Rule – rather than a provider specific consent. When a Client signs the ASCMI Form, they are authorizing the disclosure of specified categories of information for TPO purposes with their care team (those who currently have a treatment, payment, or care coordination relationship with the client). This includes disclosures of the minimum necessary data needed to coordinate care, support continuity of treatment, process payment, and carry out related administrative and operational functions. The authorization applies based on purpose and data type, not on a pre-selected list of individual providers or provider categories.

25. Do I need to include both my National Provider Identifier (NPI) Number and my organization’s Taxpayer Identification Number (TIN)?

No, Care Partners only need to include one of these identifiers – either an NPI or TIN – on the ASCMI Form. This allows for additional Care Partner types that do not typically have an NPI, such as housing providers, to use the ASCMI Form.

26. If my Client signs the ASCMI Form, what happens next?

You should provide them with a copy of their signed Form. In addition, under the California Confidentiality of Medical Information Act (CMIA), you are required to provide your Client with instructions on how they can access additional copies or a digital version. DHCS defers to Care Partners on processes for storing paper or digital forms.

Sumangguni sa seksyong Mga FAQ ng Behavioral Health Care Partners sa dokumentong ito para sa karagdagang patnubay kung isa kang Part 2 Substance Use Disorder Provider at ang iyong Kliyente ay tumanggi na pumirma sa ASCMI Form.

Mga Menor de edad at Kliyente na may mga Legal na Kinatawan

28. Who is considered a minor?

In California, a minor is generally an un-emancipated individual under the age of 18. There are three important exceptions where someone under 18 is not treated as a minor:

1. Emancipated minors: An emancipated minor is a person under the age of 18 who has legally freed themselves from the legal and physical custody and control of their parent(s) or guardian(s). As a result, they are legally responsible for their legal decisions and actions. If a minor is unemancipated, it means that their parent(s) or guardian(s) are still responsible for their legal and physical custody.
2. Married minors: Individuals who are under 18 who have received a parent or guardian’s permission and permission from the court to be married.
3. Active-duty status in the U.S. Armed Forces: Individuals who are under 18 who have permission from a parent or guardian to join the military.

More information about minor emancipation in California is available at: https://selfhelp.courts.ca.gov/emancipation.

29. For minors, when is parental consent, or the consent of a guardian, required for the sharing of information?

In general, a parent/guardian has the right to consent to the sharing of their child’s health and other personal information. Under HIPAA, the parent/guardian of an unemancipated minor has authority to consent to the release of protected health information if the parent/guardian has the authority to act on behalf of the minor in making health care decisions.

However, when the minor has the legal ability to consent to receive a particular service, independent of their parents, it is often the minor, not the parent/guardian, who will sign any authorization forms that permit the disclosure of information about that service.

30. For minors, are there instances when parent or guardian consent is not required?

Yes. If you provided care or a service to a minor without requiring their parent or guardian’s permission, because the minor was legally authorized to consent to that service, it is the minor who has the right to consent to disclosure of their health information. In such cases, their parent or guardian will not have access to those records.

31. What is a legal representative?

A legal representative is a person who has the authority to act on behalf of another. This could be a parent in the case of a minor, an individual appointed as a guardian by a court, or an individual authorized to act on behalf of an incapacitated adult.

Mga Kasosyo sa Pangangalaga sa Kalusugan ng Pag-uugali

32. Can I share my Client’s substance use disorder counseling notes with a signed Form?

No. Disclosure of substance use disorder counseling notes is outside the scope of this Form. Consent to share this type of information requires a separate, specific consent. Consult your organization’s counsel and/or privacy office to determine the appropriate consent to release information form to use.

33. Can I share my Client’s psychotherapy notes with a signed Form?

No. Disclosure of psychotherapy notes is outside the scope of this Form. The HIPAA Privacy Rule defines psychotherapy notes as notes recorded by a health care provider who is a mental health professional documenting or analyzing the contents of a conversation during a private counseling session or a group, joint, or family counseling session and that are separate from the rest of the patient’s medical record. HIPAA requires a separate, specific authorization for the release of this type of information.

34. (For Non-AB 133 Version only) What types of information are protected by the Lanterman-Petris-Short Act (LPSA)?

The Lanterman-Petris-Short Act (LPSA) protects mental health treatment records obtained during a Client’s involuntary treatment hold. You may refer to the CalAIM Data Sharing Authorization Guidance for additional details (see Section 2).

35. Is my organization a Part 2 program?

You may reference this high-level decision tree to determine if your organization is a Part 2 program. More information on Part 2 and its requirements is available in Substance Use Confidentiality Regulations. You may refer to Section 2 of the CalAIM Data Sharing Authorization Guidance for an overview of Part 2.

Ipinapalagay ba ng provider/entity (1) ang sarili bilang nagbibigay ng mga serbisyo ng substance use disorder (SUD) at nagbibigay ng diagnosis, paggamot, o referral ng SUD AT (2) tumatanggap ba ito ng tulong na pederal?

• If yes,
  • Sila ay isang Part 2 Provider
• If no,
  • Hindi sila Part 2 Provider

36. If I am a Part 2 provider and my Client declined to sign the Form, how do I obtain consent to disclose my Client’s Part 2 Substance Use Disorder information for payment purposes?

In the event that you need to obtain consent in order to be paid for the services you provide, you have the right to deny services until your client signs the ASCMI Form or another payment-specific authorization.

Mga Kasosyo sa Pangangalaga sa Pasilidad ng Pagwawasto

37. For individuals who are incarcerated or were recently incarcerated, why can certain types of criminal-legal information be shared without consent?

Care Partners serving individuals that are incarcerated or were recently incarcerated may need to share some of their criminal-legal information to enroll them in services.

You may refer to the CalAIM DSAG Toolkit for the Reentry Initiative for more information, including use case scenarios on when Client consent is required for data sharing.

38. Can I use the ASCMI Form to share data with law enforcement?

It depends on the purpose of the disclosure, and to whom the data would be disclosed.

If the purpose of disclosure is for health treatment, payment, and operations, the data can be disclosed with an ASCMI Form even to Care Partners within the criminal/legal sector (e.g., CalAIM Justice-Involved Reentry providers).

If the purpose of disclosure is for legal proceedings:

The ASCMI Form cannot be used to authorize disclosures for legal proceedings. For these purposes, a court order would be needed.

39. Can I use the ASCMI Form to share data with immigration officials?

DHCS defers to Care Partners’ legal counsel for questions about using the ASCMI Form to share data in support of care coordination with Care Partners that work in immigration facilities.

Mga Kasosyo sa Pangangalaga sa Pabahay

40. Can the ASCMI Form replace my organization’s Homelessness Management Information System (HMIS) ROI? Do my Clients need to sign both?

See FAQ #4. You may refer to the CalAIM DSAG Toolkit for Medi-Cal Housing Supports for more information, including use case scenarios on when Client consent is required for data sharing.

41. What types of housing information does the ASCMI Form cover?

The ASCMI Form covers housing information that originates from a Continuum of Care (CoC) and purpose of the disclosure is not authorized in the CoC’s NPP. This data may include:

• Mga pagsusuri sa paggamit na nakumpleto mo noong nag-enroll sa mga Kliyente sa mga serbisyo.
• Katayuan ng pabahay.
• Impormasyon sa mga benepisyo ng Enhanced Care Management at Community Supports.

Iba pang Kasosyo sa Pangangalagang Pangkalusugan

42. (For Non-AB 133 Version only) Do I need to obtain a new Form for each HIV test I administer?

Yes. California law requires that a separate authorization be obtained every time a disclosure of an HIV test result is made. The paper version of the ASCMI Form can be used to capture HIV consent each time a disclosure is needed. When an ASCMI Form is collected digitally through the Consent Management Portal (CMP), HIV test results will not be included as the CMP is unable to track whether disclosures are made at time of querying for a Client’s consent preferences. Instead, providers will need to rely on localized policies and processes to ensure compliance with the regulation.

Mga kliyente

Layunin

Ang layunin ng dokumentong ito ay magbigay sa iyo ng karagdagang impormasyon upang matulungan kang maunawaan ang ASCMI Form. Ipinapaliwanag nito:

• Bakit maaaring gusto mong payagan ang iyong mga provider na ibahagi ang iyong impormasyon sa isa't isa.
• Anong mga uri ng impormasyon ang maaari nilang ibahagi.
• Sino ang maaaring makakita ng iyong impormasyon.

Sa pamamagitan ng paglagda sa Form na ito, mas maaayos ng iyong mga provider ang iyong pangangalaga at ikonekta ka sa mga serbisyong kailangan mo. Maaari mong gamitin ang impormasyong ito upang matulungan kang magpasya kung pipirmahan ang Form. Kung mayroon kang mga karagdagang tanong tungkol sa Form o sa impormasyong ibinigay sa ibaba, mangyaring tanungin ang taong nagbabahagi ng Form sa iyo.

Pangkalahatang Impormasyon Tungkol sa ASCMI Form

1. What is the ASCMI Form?

Ang ASCMI Form ay isang dokumento na humihiling ng iyong pahintulot na payagan ang iyong Mga Kasosyo sa Pangangalaga (tingnan ang FAQ #2 sa ibaba) na ibahagi ang iyong impormasyon sa isa't isa. Makakatulong ito sa iyo na maiwasan ang pagbabahagi ng parehong impormasyon nang maraming beses o pumirma ng bagong form ng pahintulot sa tuwing kailangang ibahagi ng iyong Mga Kasosyo sa Pangangalaga ang iyong impormasyon. Maaari rin itong gumawa ng mga referral at appointment para sa iyong patuloy na mga pangangailangan sa pangangalaga sa iba pang mga provider nang mas mabilis at mas madali.

2. Who are my “Care Partners?”

Ang iyong Mga Kasosyo sa Pangangalaga ay mga tagapagkaloob o organisasyon na maaaring kailanganing ibahagi o tanggapin ang iyong impormasyon habang binibigyan ka nila ng mga serbisyo. Kabilang dito, ngunit hindi limitado sa:

• Mga tagapagbigay ng pangangalagang pangkalusugan, kabilang ang mga doktor sa pangunahing pangangalaga at mga espesyalista sa kalusugan ng isip.
• Mga provider ng sakit sa paggamit ng sangkap, gaya ng mga programa sa paggamot sa opioid at mga programa sa paggamot sa tirahan.
• Mga organisasyong nakabatay sa komunidad at mga nagbibigay ng serbisyo sa pabahay.
• Mga tagapagbigay ng pasilidad ng pagwawasto at tagapamahala ng kaso (tingnan ang FAQ #22 para sa mga detalye).
• Mga plano sa segurong pangkalusugan, kabilang ang mga plano sa pinamamahalaang pangangalaga ng Medi-Cal at mga plano sa kalusugan ng pag-uugali.
• Kwalipikadong organisasyon ng impormasyon sa kalusugan (tingnan ang FAQ #26 para sa mga detalye).
• Mga ahensya ng kalusugan ng county at mga serbisyong pantao.
• Mga ahensya ng kalusugan at serbisyong pantao ng estado.

3. What does “AB 133 Version” or “Non-AB 133 Version” mean?

Assembly Bill (AB) 133 is a California law that allows your Care Partners (members of your care team) to share some of your information without your signed consent to make it easier for them to provide you with services and to coordinate your care. The data sharing rules of AB 133 (2021) apply if one of the following pertains to you:

• Naka-enroll ka sa pinamamahalaang pangangalaga ng Medi-Cal.
• Ikaw ay tumatanggap ng mga serbisyo sa kalusugan ng pag-uugali sa ilalim ng Medi-Cal.
• Ikaw ay tumatanggap ng mga serbisyo ng pre-release habang nasa kulungan upang i-coordinate ang pagpapatala sa Medi-Cal at upang magbigay ng suporta upang matiyak na ang mga serbisyo ay magagamit sa paglabas mula sa kulungan.

If none of the above three options apply to you, you will be asked to sign the Non-AB 133 Version. Anyone can choose to sign the non-AB 133 Form, including if the three options above do apply to you. Your Care Partner will provide you with the version of the Form that you should sign.

4. Why am I being asked to sign the Form?

Signing the Form will help your Care Partners to better recommend services and supports to help meet your health care or other needs. They will also be able to refer you to these services and help to coordinate them.

For example, if you need support with finding housing, and you have signed the ASCMI Form, your doctor can share more information about you with a housing provider. This can help the housing provider find the housing that is best for you and your needs.

5. Why should I sign the Form?

Signing the Form means your Care Partners can share more information about you with other Care Partners providing you with services. It can help stop delays in getting you connected to other services. For example, if you have a substance use disorder, your provider can share information with a housing provider to help you find housing that will help you with your substance use treatment.

6. Do I have to sign the Form?

No. Signing the Form is optional. If you sign the Form, your Care Partners can share more information about you with other Care Partners providing you with services.

7. What happens if I don’t sign the Form? Will I be denied services if I do not sign this Form?

In most cases, you will not be denied care or services if you do not sign the Form. But signing the Form will make it easier for your Care Partners to provide you with care and coordinate services on your behalf, such as referrals to other providers.

In some cases, Care Partners must be able to share your information in order to receive payment for the services they provide. If they cannot share your information for this purpose, they may ask you to pay for your services yourself. You should ask your Care Partner about other options if you are in this situation.

8. Does signing this Form enroll me in Medi-Cal or other programs and services?

No. Signing this Form does not enroll you in Medi-Cal or other programs and services. However, signing the Form means that your Care Partners will be able to better identify programs and services that you may qualify for and connect you to them.

9. What happens after I sign the Form?

Your Care Partner will keep a record of your signed Form. They may also share a copy of the Form with your other Care Partners to make sure your information is only shared if you have given permission. If you want to change your consent preferences in the future, please reach out to the Care Partner that collected your Form.

10. Do I need a representative (parent, guardian, or legal representative) to sign this Form for me?

If you are 17 or younger, you and either your parent or legal guardian (or representative) should sign the Form. For certain types of treatment, only your signature will be necessary and not your parent, guardian, or representative’s signature. The Care Partner who gives you the Form will help explain those cases and who should sign the form.

If you are 18 or older, you are the only person who needs to sign the Form, unless you have another person (a legal representative) who is allowed to act on your behalf.

11. What is a legal representative?

A legal representative is an individual who is legally authorized to act on behalf of a Client in making health care decisions and managing their health information. This may include, but is not limited to, a parent or guardian of a minor, an individual with health care power of attorney, a court-appointed guardian, or a conservator.

A legal representative may sign forms, such as the ASCMI Form, when they have the legal authority to do so.

12. For minors, when is parental consent, or the consent of a guardian, required for the sharing of information?

In general, a parent/guardian has the right to consent to the sharing of their child’s health and other personal information. Under HIPAA, the parent/guardian of an unemancipated minor has authority to consent to the release of protected health information if the parent/guardian has the authority to act on behalf of the minor in making health care decisions.

However, when the minor has the legal ability to consent to receive a particular service, independent of their parents, it is the minor, not the parent/guardian, who will sign any authorization forms that permit the disclosure of information about that service. For more information, see the Data Sharing Authorization Guidance 2.1.

For example, state law permits a minor to consent to medical care related to the diagnosis, treatment, and prevention of sexually transmitted diseases, and infectious, contagious, or communicable diseases. Because the minor can consent to this treatment, they would be responsible for signing any authorization forms that permit the disclosure of information about these services, and the parent or guardian would not have access to these records.

Layunin ng Pagbabahagi ng Impormasyon

13. Why does my information need to be shared?

Your Care Partners may need to share your information to:

• I-coordinate ang iyong pangangalaga.
• Nagbibigay sa iyo ng medikal, dental, kalusugang pangkaisipan, at paggamot at mga serbisyong may karamdaman sa paggamit ng sangkap.
• Tumanggap ng bayad mula sa iyong carrier ng health insurance para sa paggamot at mga serbisyong ibinigay sa iyo.
• Ikonekta ka sa mga programa, serbisyo, at mapagkukunan na makakatulong sa pagpapabuti ng iyong kalusugan at kapakanan.

Ang iyong Mga Kasosyo sa Pangangalaga ay maaari lamang magbahagi o humiling ng iyong impormasyon para sa isang partikular na layunin, tulad ng mga nakalista sa itaas. Ayon sa batas, maaari lamang nilang ibahagi ang pinakamaliit na halaga ng impormasyong kailangan para sa kadahilanang iyon. Sa karamihan ng mga kaso, hindi nila maa-access o maibabahagi ang iyong buong tala.

14. Can I allow my Care Partners to share my information for just payment and not other purposes?

Not at this time. Your consent with the ASCMI Form applies to all of the purposes listed above. However, you can talk with your Care Partner about other options if you would like to allow sharing only for certain purposes, like payment.

Mga Uri ng Impormasyon

15. What information about me may be shared even if I do not sign this Form?

Your Care Partners legally can and will share some types of your information even if you do not sign the Form. They can share your information to provide care or coordinate your treatment and services, receive payment for services, and run their organizations to provide quality care.

Examples of information that can be shared without your signed consent include:

• Ilang impormasyong medikal at pangkaisipang kalusugan.
• (AB 133 Version Only) Impormasyon sa Substance Use Disorder na hindi protektado ng pederal na batas 42 CFR Part 2 (karaniwang tinutukoy bilang Part 2). Sumangguni sa FAQ #14 para sa higit pang mga detalye tungkol sa impormasyon sa paggamit ng sangkap na protektado ng Bahagi 2.
• Impormasyon sa Seguro sa Kalusugan
• (AB 133 Version Only) Limitadong kriminal na legal na impormasyon, kabilang ang impormasyon sa pag-book, mga petsa at lokasyon ng pagkakulong, at katayuan ng parol.

16. What information about me may be shared if I sign this form?

Kailangan ng Mga Kasosyo sa Pangangalaga ang iyong pahintulot na magbahagi ng iba pang mga uri ng impormasyon tungkol sa iyo. Kung pipirmahan mo ang Form na ito, maaaring ibahagi ng iyong Mga Kasosyo sa Pangangalaga ang mga uri ng impormasyon na iyong nilagyan ng tsek na "Oo" sa tabi ng Seksyon 2.3 ng Form. Ang mga uri ng impormasyon na maaari mong mapagpasyahan na ibahagi ay:

Bersyon ng AB 133:

• Substance Use Disorder treatment information
• Some housing information collected by your Continuum of Care (such as intake assessment completed by Continuum of Care organization).

Non-AB 133 Version:

• Substance Use Disorder treatment information
• Some housing information collected by your Continuum of Care (such as an intake assessment completed by Continuum of Care organization).
• Mental Health information (such as treatment records, assessments).
• Intellectual and Developmental Disability information (such as developmental service records, Individual Program Plan, Regional Center eligibility assessment).
• HIV Test Results (note – to share HIV test results you will need to sign a new paper consent form each time that data may need to be shared)
• Mga Resulta ng Genetic Test.

17. Can I choose what types of information about me are shared?

Yes. You can choose what special categories of information you want shared by using the checkboxes in Section 2.3, titled “Your Consent.” The checkboxes show what information you agree to share.

If you check “Yes” for any of these information types, your Care Partners can share that information with each other to help coordinate your care.

If you check “No,” you may be asked for your permission to share that information again in the future if your Care Partners need it in order to provide you with the best care.

18. What is 42 C.F.R. Part 2? How do I know if my substance use disorder information is protected by this law?

42 C.F.R. Part 2 is a federal law that protects the privacy of people being treated for a substance use disorder. It only applies to substance use disorder information collected by a special type of provider or organization. These types of providers are those that provide substance use diagnosis, treatment, or referral for substance use disorders and receive federal funds to support their organization.

If your substance use disorder information is protected by this law, your Care Partners can only share this information with your written permission. Your Care Partner can help you determine if your substance use disorder information is protected by this law.

19. Does consenting to share my Part 2 information in this Form mean my substance use disorder counseling notes will be shared?

Hindi. Ang mga tala sa pagpapayo sa karamdaman sa paggamit ng sangkap ay mga tala ng tagapagkaloob sa kanilang pakikipag-usap sa isang pasyente sa panahon ng sesyon ng pagpapayo, na nakaimbak nang hiwalay sa iba pang Bahagi 2 na impormasyon tungkol sa sakit sa paggamit ng sangkap. Ang pahintulot na ibahagi ang ganitong uri ng impormasyon ay nangangailangan ng hiwalay, partikular na pahintulot.

20. Does consenting to share my mental health information in this Form mean my psychotherapy notes will be shared?

Hindi. Ang mga tala sa psychotherapy ay mga tala na ginawa ng isang propesyonal sa kalusugan ng isip sa isang pag-uusap sa panahon ng isang pribadong sesyon ng pagpapayo o isang sesyon ng pagpapayo sa grupo, pinagsama-samang, o pamilya. Ang mga ito ay iniimbak nang hiwalay mula sa iba pang talaan ng medikal ng pasyente at nangangailangan ng hiwalay, partikular na pahintulot.

21. If I do not sign the Form, will any of my information be shared?

Kung pipiliin mong hindi lagdaan ang Form, hindi ibabahagi ng iyong Mga Kasosyo sa Pangangalaga ang impormasyong inilarawan sa Seksyon 2.3. Ngunit ang ilang uri ng impormasyon, tulad ng inilarawan sa Seksyon 1.3 ng Form at sa FAQ #14, ay maaari pa ring ibahagi.

22. What is a Homeless Management Information System?

Ang Homeless Management Information System ay ginagamit ng mga provider ng serbisyo sa pabahay upang pamahalaan ang impormasyon tungkol sa mga taong nakakakuha ng mga serbisyo at suporta sa pabahay. Halimbawa: ang Homeless Management Information System ay maaaring gamitin upang mangolekta at mag-imbak ng impormasyon sa pagtatasa ng pabahay upang ilagay ang mga tao sa tamang pabahay batay sa kanilang mga pangangailangan. Maaaring kailanganin ng Iyong Mga Kasosyo sa Pangangalaga na magbahagi ng impormasyon sa mga tagapagbigay ng pabahay na gumagamit ng Homeless Management Information System.

Sino ang Maaaring Magbahagi at Makatanggap ng Aking Impormasyon?

23. If I sign the Form, who will my information be shared with?

If you sign the Form, the information that you allow to be shared in Section 2.3 of the Form will only be shared among your Care Partners. The Form does not allow individuals and organizations that are not providing you with treatment and services to receive your information. See FAQ #2 for examples of Care Partners.

24. Can my Care Partners re-share my personal information?

Yes. Your Care Partners can re-share your personal information with individuals and organizations that are also involved in your care, but only as they are legally allowed to do so.

For example, if you give consent to share substance use disorder information that is protected by 42 C.F.R. Part 2, your health plan, insurance provider, or health care provider can re-share it for purposes of providing you with treatment, receiving payment for services provided to you, and to provide quality care.

25. Can I exclude specific people or organizations from sharing and receiving my information if I sign this Form?

Not at this time. If you give permission to share your information with this Form, all individuals or organizations that are providing your care could see and use this Form to share and receive your information if they need to. If you have concerns about specific individuals or organizations involved in your care accessing your information, consult your Care Partner.

26. If I sign this Form, will police or immigration authorities have access to my confidential information?

No. Signing the ASCMI Form does not mean that police or immigration authorities can automatically access or receive your confidential information. However, there are ways for the police or immigration authorities to potentially access your information, for example, with a court order. The substance use disorder information described in FAQ #17 cannot be shared for use in civil, administrative, or criminal investigations, proceedings, or prosecutions, sentencing, immigration enforcement, or family court proceedings against you without a court order.

27. What is a Qualified Health Information Organization?

A qualified health information organization is an organization that helps Care Partners exchange information about their Clients. They make sure the information is shared securely based on their Clients’ consent preferences.

Ina-update ang Aking Impormasyon sa Pahintulot

28. How do I get a copy of this Form?

You can ask your Care Partner that collected the Form from you for a copy.

29. How long is my consent good for?

Your signed Form will be good for one year, with the below exception:

If you are 17 and turn 18 within a year of signing the Form, you will be asked to sign a new Form.

Please note that you may change your consent preferences for specific information types or take back your consent entirely before it expires (see FAQ #30 below).

30. Can I change my consent preferences? If so, how?

Yes. Contact your Care Partner if you wish to change your consent preferences. They will provide you with a revocation form to complete to revoke consent for all information types. After you have completed the revocation form, your Care Partner may ask you to complete a new ASCMI Form with your new consent preferences. Partial revocation for specific types of data is not permitted via the Revocation Form.

31. What happens when my consent expires?

Kapag nag-expire ang iyong pahintulot, maaaring hilingin sa iyo ng iyong Care Partner na pumirma ng bagong ASCMI Form kung kailangan nila ng iyong espesyal na pahintulot na ibahagi ang mga uri ng impormasyon sa Seksyon 2.3 ng Form.

32. If I change health plans or move to a different county before my consent expires, will my consent follow me?

Hindi magbabago ang iyong pahintulot kung babaguhin mo ang mga planong pangkalusugan o lumipat sa ibang county bago mag-expire ang iyong pahintulot. Maaari mong hilingin na ang iyong Kasosyo sa Pangangalaga na nangongolekta ng iyong nilagdaang Form ay ibahagi ang Form sa iba sa iyong bagong county. Hindi ka susundan ng Form kung lilipat ka sa ibang estado.

33. If my Medi-Cal eligibility status changes before my consent expires, will my consent still be active?

Hindi. Ang katayuan ng pagiging karapat-dapat sa Medi-Cal ay nakakaapekto kung pipirmahan mo ang AB 133 o Hindi AB 133 na Bersyon ng Form. Kung nagbago ang iyong katayuan sa pagiging karapat-dapat sa Medi-Cal, hihilingin sa iyo ng iyong Kasosyo sa Pangangalaga na pumirma ng bagong Form.