Authorization for Disclosure of Confidential Treatment Records

Authorization for Disclosure of Confidential Treatment Records
In compliance with Federal confidentiality rules set forth in 42 CFR Part 2, and HIPAA, substance use and/or mental health treatment records maintained by Health Solutions are confidential and will not be released, unless otherwise provided for by the regulations, without written consent from the individual or their personal representative.
Client/Guardian Name*

First NameLast Name
I authorize Health Solutions to send, receive, exchange, use, or disclose the substance use and mental health treatment information of the individual named below:
Patient Name*
D.O.B*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
I authorize the information to be disclosed to, and discussed with, the following individual(s) or organization(s) When using a general designation, you have the right to obtain, upon request, a list of entities to whom your information has been disclosed, pursuant to the general designation
Name of Individual or Organization*
Purpose of Release (as specific as possible, ie: Care Coordination, Requirement of probation, Family Support with appointments)*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
The type and amount of information to be disclosed is as follows (as specific as possible):
All of my substance use/mental health disorder treatment information
OR One or more of the following
Assessments & EvaluationsAppointment InformationMedications & dosagesPrescriber NotesClinical NotesDiagnosisToxicology and Laboratory resultsCrisis NotesDischarge Summary & RecommendationsVocational DocumentationOther
(Optional) from (date)
(Optional) from (date)

MonthDayYear
Date
to (date)

MonthDayYear
Date
I understand, unless otherwise revoked or withdrawn by me, this authorization will automatically expire, upon one year from the signature date, whichever comes first.

I understand that I may revoke this authorization in writing at any time except to the extent that action has been taken in reliance on this authorization. I understand that my revocation will only apply to future sharing of information and will not apply to any sharing of information prior to the date of revocation.

I understand that I might be denied services if I refuse to consent to a disclosure for purposes of treatment, payment, or health care operations, if permitted by law. I will not be denied services if I refuse to consent to a disclosure for other purposes.
The person signing this document is:*

PatientAuthorized Personal Representative
I have been offered a copy of this form.*

Clear
Signature of Patient or Authorized Personal Representative
Date*

MonthDayYear
Date
If signed by a Personal Representative, please state relationship and authority to consent
This authorization reflects the requirements of 42 C.F.R. Part 2 and HIPAA.
I REVOKE the above

Clear
Should be Empty:

Authorization for Disclosure of Confidential Treatment Records

OR One or more of the following