WebCom Page Header Authorization to Share Confidential Member Information Frequently Asked Questions (FAQs) Care Partners Clients Care Partners Purpose 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. General Information About ASCMI What is the ASCMI Initiative? The ASCMI Initiative is a statewide effort to promote and standardize the exchange of Clients’ sensitive 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 platform to store completed ASCMI Forms. DHCS envisions Care Partners will be able to access the platform 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 platform are forthcoming. 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: Coordinate their care. Provide them with medical, dental, mental health, and substance use disorder treatment and services. Obtain payment for treatment and services you provide. Help connect them to programs, services, and resources. The Form complies with authorization form requirements under relevant federal and state data sharing laws (see FAQ #11-12) and details which types of information require consent to share data. 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 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 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. How does the Form differ from additional consent to release information forms (e.g., Homeless Management Information System (HMIS) Release of Information Form)? The Form is intended to promote care coordination by enabling Care Partners within and across sectors (e.g., behavioral health, criminal-legal, housing) to exchange information for Clients receiving various services (e.g., physical or behavioral health services, social supports). 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 the appropriate release of information form to use. 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? You are not required to use the Form. However, DHCS highly recommends Care Partners use the Form as their standard consent form. 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 of information form. Is the Form a data sharing agreement? No. The Form documents a Client’s consent to share or not to share specific types of information that are listed in Section 2.3 of the Form (see FAQ #9). The Form does not establish a data sharing agreement between Care Partner organizations. What is the benefit of using the Form? There are many benefits to using the Form, including: It is written in plain language, at a reading level accessible to individuals with a middle school education or higher. It reduces administrative burden, because the standard Form can be used across multiple sectors. Your Client can authorize sharing of multiple types of information across their care team in accordance with relevant data sharing and privacy laws. It aligns with state and federal changes to data sharing and privacy laws, such as the updated 2024 42 C.F.R. Part 2 (“Part 2”) regulations. How long is my Client’s consent active? When does their consent expire? Generally, consent will expire one year from the date of signature for both forms. However, if your client is 17, their consent will only last until they turn 18 or until their guardianship changes, which may be less than one year. However, Clients or their parent, guardian, or legal representative retain the right to revoke their consent or modify their consent preferences before it expires if they choose to. What types of information does the Form authorize to be shared? The AB 133 Version can be used to obtain consent for sharing the following types of information: Substance Use Disorder information protected by Part 2 (e.g., diagnoses, prescription details, treatment records). Housing information (e.g., housing assessment completed by Coordinated Entry). The Non-AB 133 Version can be used to obtain consent for sharing the following types of information: Substance Use Disorder information protected by Part 2 (e.g., diagnoses, prescription details, treatment records). Substance Use Disorder information not protected by 42 C.F.R. Part 2. Housing information (e.g., housing assessment completed by Coordinated Entry). Mental Health information (e.g., treatment records, assessments). Intellectual and Developmental Disability information (e.g., developmental service records, Individual Program Plan, Regional Center eligibility assessment). HIV Test Results. Genetic Test Results. 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. 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. Care Partners that serve Clients to whom AB 133 does not apply may refer to the State Health Information Guidance developed by the California Health and Human Services Agency (CalHHS) for additional information. 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 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). AB 133 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 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. Laws that only apply to the Non-AB 133 Version include the following: California Confidentiality of Medical Information Act (CMIA). California Health and Safety Code Section 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. 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. If I receive permission (via the Form) to access my Client’s information, can I redisclose to additional Care Partners in the future? Redisclosure permissions vary by information type and depending on what type of entity you are. For example, if you are a HIPAA-covered entity or business associate, you can redisclose all types of information you receive pursuant to the ASCMI Form, including Part 2 information, as long as you’re doing so in accordance with HIPAA (e.g., for purposes of treatment, payment, and care coordination). If you are not a covered entity or business associate, the purposes for which you can redisclose are more limited. Care Partners should consult with their privacy officers with questions regarding redisclosure. See additional redisclosure considerations in FAQ #12. Administering the ASCMI Form Which version of the Form should my Client sign? Refer to FAQ #3. Is there any guidance for implementing the Form? When should I ask my Client to sign the Form? DHCS defers to Care Partners on determining when to administer the Form based on your organization’s workflow and the specific context in which you are providing services to an individual. In some cases, Care Partners may administer the Form at the point of intake/enrollment or during the course of providing services to a Client. Other Care Partners may administer the Form when a Client’s data must be shared. Can I administer the Form during a telehealth visit?Yes. An electronic signature is valid, and under federal law, an electronic signature can include an oral recording. You may send your Client an electronic copy to sign or read the ASCMI Form to them and record their verbal consent. 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. Is there any benefit to presenting my Client with the Form if none of the “special permissions” apply to them? Yes. If the “special permissions” apply to your Client in the future, obtaining their permission when administering the Form can allow you to exchange their information when needed. Should my Client still sign the Form, even if they do not grant permission to share any information types that require their special permission? Yes. You should still document your Client’s consent preferences, even if they decline the disclosure of any data authorized by the Form by selecting the “No” checkbox. This avoids re-requesting your Client’s consent to share their data and records their request to not share that data. However, signing the Form is optional, and your Client may decline to complete the Form. Care Partners should make Clients aware that some of their data may still be shared (see FAQ #11) and they may get asked again to complete the Form in the future. 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. Refer to the Behavioral Health Care Partners FAQs section in this document for additional guidance if you are a Part 2 Substance Use Disorder Provider and your Client declines to sign the ASCMI Form. 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) (applicable to the Non-AB 133 Version), 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.Refer to the Behavioral Health Care Partners FAQs section in this document for additional guidance if you are a Part 2 Substance Use Disorder Provider and your Client declines to sign the ASCMI Form. Minors and Clients with Legal Representatives Who is considered a minor?In California, a minor is generally any unemancipated individual under the age of 18. 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. 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. 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. Behavioral Health Care Partners 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. 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. (For Non-AB 133 Version only) What types of information are protected by the Lanterman-Petris-Short (LPS) Act?The LPS Act 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). 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. Does the provider/entity (1) hold itself out as providing substance use disorder (SUD) services and provide SUD diagnosis, treatment, or referral AND (2) does it receive federal assistance? If yes They are a Part 2 Provider If no They are not a Part 2 Provider 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. Correctional Facility Care Partners 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. Housing Care Partners Can the ASCMI Form replace my organization’s Homelessness Management Information System (HMIS) ROI? Do my Clients need to sign both?See FAQ #5. 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. What types of housing information does the ASCMI Form cover?The ASCMI Form covers housing information such as: Intake assessments that you have completed when enrolling Clients in services. Housing status. Enhanced Care Management & Community Supports benefits information. Other Health Care Partners (For Non-AB 133 Version only) Do I need to obtain a new Form for each HIV or genetic test I administer?Yes. California law requires that a separate authorization be obtained every time a disclosure of an HIV or genetic test result is made. Clients Purpose The purpose of this document is to provide you with additional information to help you understand the ASCMI Form. It explains: Why you might want to allow your providers to share your information with each other. What types of information they can share. Who may see your information. By signing this Form, your providers can better coordinate your care and connect you with the services you need. You may use this information to help you decide whether to sign the Form. If you have additional questions about the Form or the information provided below, please ask the person sharing the Form with you. General Information About the ASCMI Form What is the ASCMI Form? The ASCMI Form is a document requesting your permission to allow your Care Partners (see FAQ #2 below) to share your information with each other. This can help you avoid having to share the same information multiple times or sign a new consent form each time your Care Partners need to share your information. It can also make referrals and appointments for your ongoing care needs with other providers faster and easier. Who are my “Care Partners?” Your Care Partners are providers or organizations that may need to share or receive your information while they are providing you with services. This includes, but is not limited to: Health care providers, including primary care physicians and mental health specialists. Substance use disorder providers, such as opioid treatment programs and residential treatment programs. Community-based organizations and housing service providers. Correctional facility providers and case managers (see FAQ #22 for details). Health insurance plans, including Medi-Cal managed care plans and behavioral health plans. Qualified health information organizations (see FAQ #26 for details). County health and human services agencies. State health and human services agencies. What does “AB 133 Version” or “Non-AB 133 Version” mean? Assembly Bill (AB) 133 is a California law that allows your Care Partners 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 apply if one of the following pertains to you: You are enrolled in Medi-Cal managed care. You are receiving behavioral health services under Medi-Cal. You are receiving pre-release services while in jail to coordinate enrollment in Medi-Cal and to provide support to ensure services are available upon release from jail. If none of the above three options apply to you, you will be asked to sign the Non-AB 133 Version. Your Care Partner will provide you with the version of the Form that you should sign. 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. 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. 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. 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 care and services.In some cases, Care Partners must be able to share your information in order to receive payment for the services they provide. They may deny you services if you do not allow them to share your information for this purpose. You should ask your Care Partner about other options if you are in this situation. 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. 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. 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. If I am under 18, will my parent or legal guardian be able to see my personal information? In some cases, your information can be shared with your parent or legal guardian. However, if you received care or a service without needing your parent’s or guardian’s permission, your parent or guardian will not have access to information related to that care or service, unless you give permission to share that information with them. For example, if you are under 18 and you receive reproductive health services, your parent will not have a right to see information related to those services, such as your prescription for birth control. The Care Partner who gives you the Form will help explain who may be able to see your information, and who may not. Purpose of Information Sharing Why does my information need to be shared? Your Care Partners may need to share your information to: Coordinate your care. Provide you with medical, dental, mental health, and substance use disorder treatment and services. Receive payment from your health insurance carrier for treatment and services provided to you. Connect you to programs, services, and resources that can help improve your health and wellbeing. Your Care Partners can only share or request your information for a specific purpose, like the ones listed above. By law, they can only share the smallest amount of information needed for that reason. In most cases, they cannot access or share your entire record. 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. Types of Information 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: Some medical and mental health information. (AB 133 Version Only) Substance Use Disorder information not protected by federal law 42 C.F.R. Part 2 (commonly referred to as Part 2). Refer to FAQ #14 for more details about substance use information protected by Part 2. Health insurance information (AB 133 Version Only) Limited criminal legal information, including booking information, dates and location of incarceration, and parole status. What information about me may be shared if I sign this form? Care Partners need your permission to share other types of information about you. If you sign this Form, your Care Partners may share the types of information that you have checked “Yes” next to in Section 2.3 of the Form. The types of information that you can decide to share are: AB 133 Version: Substance Use Disorder information protected by 42 C.F.R. Part 2 (e.g., diagnoses, prescription details, treatment records). Housing information (e.g., intake assessment completed by Continuum of Care organization). Non-AB 133 Version: Substance Use Disorder information protected by 42 C.F.R. Part 2 (e.g., diagnoses, prescription details, treatment records). Substance Use Disorder information not protected by 42 C.F.R. Part 2. Housing information (e.g., intake assessment completed by Continuum of Care organization). Mental Health information (e.g., treatment records, assessments). Intellectual and Developmental Disability information (e.g., developmental service records, Individual Program Plan, Regional Center eligibility assessment). HIV Test Results. Genetic Test Results. 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. 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. Does consenting to share my Part 2 information in this Form mean my substance use disorder counseling notes will be shared? No. Substance use disorder counseling notes are a provider’s notes on their conversations with a patient during a counseling session, which are stored separately from other Part 2 substance use disorder information. Consent to share this type of information requires a separate, specific consent. Does consenting to share my mental health information in this Form mean my psychotherapy notes will be shared? No. Psychotherapy notes are notes made by a mental health professional on a conversation during a private counseling session or a group, joint, or family counseling session. These are stored separately from the rest of a patient’s medical record and require a separate, specific consent. If I do not sign the Form, will any of my information be shared? If you choose not to sign the Form, your Care Partners will not share the information described in Section 2.3. But some types of information, as described in Section 1.3 of the Form and in FAQ #14, may still be shared. What is a Homeless Management Information System? A Homeless Management Information System is used by housing service providers to manage information about people who get housing services and supports. For example: the Homeless Management Information System could be used to collect and store housing assessment information to place people into the right housing based on their needs. Your Care Partners may need to share information with housing providers who use a Homeless Management Information System. Who May Share and Receive My Information? If I sign the Form, whom 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 treatment and services to receive your information. See FAQ #2 for examples of Care Partners. 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. 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. 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. 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. Updating My Consent Information How do I get a copy of this Form? You can ask your Care Partner that collected the Form from you for a copy. 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 #29 below). Can I change my consent preferences? If so, how?Yes. Contact your Care Partner if you wish to change your consent preferences. If you want to take back your consent entirely, they will ask you to complete the “ASCMI Revocation Form.” If you only want to change your preferences for some types of information, they will ask you to sign a new Form. What happens when my consent expires? When your consent expires, your Care Partner may ask you to sign a new ASCMI Form if they need your special permission to share the information types in Section 2.3 of the Form. If I change health plans or move to a different county before my consent expires, will my consent follow me? Your consent does not change if you change health plans or move to a different county before your consent expires. You can request that your Care Partner that collected your signed Form share the Form with others in your new county. The Form would not follow you if you were to move to a different state. If my Medi-Cal eligibility status changes before my consent expires, will my consent still be active? No. Medi-Cal eligibility status impacts whether you will sign the AB 133 or Non-AB 133 Version of the Form. If your Medi-Cal eligibility status changes, your Care Partner will ask you to sign a new Form. WebCom Page Navigation WebCom Page Title WebCom Page Main Content