Medical Record Release Authorization (HIPAA)

HIPAA MENTAL HEALTH MEDICAL RECORDS RELEASE FORM

The purpose of this form (the “Authorization”) is to obtain your consent to release your protected health information or mental health medical records. Please complete all sections of this form. If any sections are left blank, this form will be invalid and it will not be possible for your health information to be shared as requested.

Patient Information

Authorized Party

I, the Patient named above, give permission to the following “Authorized Party” to release my protected health information or mental health medical records (collectively referred to as “PHI”) in accordance with the terms of this Authorization form:

Disclosure

I, the Patient named above, give permission to the Authorized Party to release my PHI to the following party:

I give permission to the party described above to receive my PHI as described in this Authorization form. I understand that the person(s)/organization(s) listed above may not be covered by state and/or federal rules governing privacy and security of data and may be permitted to further share the information that is provided to them.

Method of Disclosure

I, the Patient named above, give permission to the Authorized Party to disclose my PHI via the following methods (check all that apply):

(*note that email may not be a secure method of communication)

I authorize release of my PHI in the following formats (select all that apply):

Electronic copy or access via web portal

Hard Copies

Protected Health Information

I, the Patient named above, give permission to the Authorized Party to disclose the following PHI and mental health records (select all that apply):

ALL HEALTH Psychosocial Educational INFORMATION Evaluation Information Assessment Psychological Discharge/Transfer Diagnosis Evaluation Summary Treatment Plan Psychiatric Evaluation Continuing Care Plan /Summary Current Treatment Demographic Medication & Update Information Management Presence/Participation Other (specify):

I authorize the Authorized Party to obtain, review, and verify my current and past prescription medication history from pharmacies, pharmacy benefit managers, prescription monitoring programs (including state prescription drug monitoring programs), and other healthcare providers for purposes of evaluation, treatment planning, medication management, and continuity of care. I understand this may include medication names, dosages, prescribing providers, dates of prescriptions, and pharmacy records.

Your initials are required to release the following types of PHI. Please initial next to the categories below that you give authorization to release. If you do not wish to release these types of information then do not initial below.

Initial

____ Alcohol, drug, and substance abuse records ____ Genetic information (including genetic test results) ____ HIV/AIDS test results and treatments

* Please note that this Authorization form does NOT include psychotherapy notes – if requesting, you must fill out a separate authorization form.

Dates

I would like the PHI described above to be released for the following dates (select one):

All dates

Only those records from the start date of: ____/____/____ to the end date of: ____/____/____

Purpose

The reason for disclosure of the PHI is (select all that apply):

At the patient’s Employment Disability request Legal purposes determination To receive payment Personal use Other (specify):

School

Termination

This Authorization will terminate (choose one):

Upon sending a written notice of revocation to the Authorized Party

Revocation

I, the Patient described above, understand that I have the right to revoke this Authorization any time. If I revoke this Authorization, I understand that I must do so in writing at the Authorized Party’s address as listed on page one of this Authorization. I understand that the revocation will not apply to information that has already been released in response to this Authorization. I understand that the revocation will not apply to my insurance company, Medicaid, and Medicare.

Acknowledgment of Rights

By signing this Authorization form, I, the Patient described above, understand that:

a. I have the right to revoke this Authorization, in writing at any time, except where uses or disclosures have already been made based upon my original permission.

b. Uses and disclosures already made based upon my original permission cannot be taken back.

c. Once the above information is disclosed, it may be redisclosed by the recipient and the information may not be protected by federal privacy laws or regulations.

d. Completing this Authorization form is voluntary and that treatment will not be denied if I refuse to sign this form.

e. I will receive a copy of this Authorization after I have signed it.

f. I may inspect or copy the information to be used or disclosed.

g. A copy of this Authorization is as valid as the original.

h. My treatment, payment, enrollment, and/or eligibility or benefits is NOT in any way conditioned upon nor will be affected by my signing or refusal to sign this form.

I certify that I have read and fully understand the statements above on all pages and I consent fully and voluntarily to its contents.

* If patient is unable to sign on behalf of self, then complete the following section:

(e.g., parent, spouse, representative, guardian, etc.)

Reason: Minor Incapacitated

* If you are a legal representative of the person whose information you are requesting, you must provide documentation proving your valid legal authority to request this information (e.g., power of attorney, healthcare surrogate form, court order, appointment of a guardianship, order appointing personal representative, letter of administration, etc.).

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