Authorization for Disclosure of Information Disclosure of Information Please enable JavaScript in your browser to complete this form.Disclosure of InformationMental HealthDrugs/ AlcoholOtherNameFirstLastAuthorization is hereby given to exchange information in written, verbal, or electronic form regarding the above named individual between the following agencies and/or individuals to be used for the purpose(s) of:AssessmentCoordination of serviceIndividual RequestInsuranceLegalOtherAll information requested is covered by federal regulation 45 C.F.R. the Health Insurance and Portability Act (HIPAA). Parts 160 and 164. Drug and alcohol information is covered by federal regulation 42 C.F.R. Part 2.Blank 0 (copy)I authorize the following agency or individual (please include address):Blank 0After case/ Discharge Plan After case/ Discharge Plan Current Medication Current Medication Drug/ Alcohol Information / Evaluation Drug/ Alcohol Information / Evaluation Financial resources & Eligibility Financial resources & Eligibility Individual Education Plan Individual Education Plan Medical History Medical History Progress Reports / Summary of treatment Progress Reports / Summary of treatment Blank 0 (copy) (copy)To release and /or receive information from the following agency or individual (please include the address):Blank 0 (copy)Psychiatric History and DiagnosisPsychiatric History and Diagnosis Psychological Testing Information Psychiatric History and Diagnosis Social History Social History Treatment/ Services PlanTreatment/ Services PlanOtherOtherIntelligence testing resultsIntelligence testing resultsPsychotherapy notesPsychotherapy notes Determining eligibility for benefits or programDetermining eligibility for benefits or programBottom DescriptionIf requested record includes drug and alcohol information. I understand that my alcohol and drug treatment records are protected under the federal regulations governing Confidentiality of Alcohol and Drugs Abuse Patient Record, 42 C.F.R. part 2 and cannot without my written consent unless otherwise provided for in the regulations. Bottom Description 1I understand this authorization may be revoked at any time, except to the extent that action has already been taken in reliance on this Authorization. I understand if I wish to revoke this authorization, I must do so in writing and present my written revocation to the Complete Behavioral Health. Bottom Description 3Unless otherwise revoked, this Authorization will expire on the following date, event or condition . If I failed to specify an expiration date event or condition, this Authorization will expire six (6) months from the date below. I understand this authorization is voluntary. I can refuse to sign this Authorization. I need not sign this Authorization to receive treatment. I understand that I may inspect or copy the information to cause or disclose it, as provided in 45 CFR 164.524. I understand that any disclosure and the information may no longer be protected by federal confidentiality laws. Date: Person Served Signature: Witness:Authority of Personal Representative: Date:Personal Representative: Bottom Description 4I have reviewed the HIPAA Notice of Privacy Practices information and agree. At my request, I am entitled to receive a copy of my rights to privacy.Date: Person Served Signature: Witness: Authority of Personal Representative: Date:Personal Representative: Submit
