Authorization to Send, Receive and/or Exchange Healthcare Information

Authorization to Send, Receive and/or Exchange Healthcare Information
Client Name*

First NameLast Name
D.O.B*

MonthDayYear
Date
As a Health Solutions client, I understand my treatment records, to include any medical, behavioral, and/or substance records, are protected under federal law, including 42 CFR Part 2 and HIPAA, and any applicable state laws. My treatment records can only be used or disclosed with my written consent, except as permitted by 42 CFR Part 2, HIPAA, and applicable state.
I authorize:

Health Solutions

41 Montebello Road

Pueblo, CO 81001

PH: 719-545-2746

Fax: 719-545-4100

and the person(s) or organization(s) listed below to send, receive, and exchange my health information as describer in this authorization. This authorization allows two-way communication between Health Solutions and the listed party.
Name of Individual or Organization (External Agency)*
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Types of Services to be Disclosed:*

All Treatment Info: MED, BH & SUDDiagnosisHIV/AIDS StatusPrescriber NotesAppointment InformationDischarge PlanMed9 FormProgress NotesClinicial Assessment (Intake)DUI Education Progress DocumentationMedication InformationTransportationCrisis NotesEducation Info. & Vocation Info.Treatment PlansOther
SUD COUNSELING NOTES: I agree to the use and disclosure of my substance use disorder (SUD) counseling notes. A Part 2 program may not require me to check this box as a condition of treatment, payment, enrollment in a health plan, or eligibility for benefits.
The information will be used for the following purposes:*

Additional Evaluation or TreatmentMulti-Agency Coordinationreports to Court or Other AgenciesClient RequestObtaining Client Resources or BenefitsRepresentative/Guardian's RequestContinuity of CareService PlanningLegal ProceedingsProfessional ConsultationsTx, Payment or Healthcare OperationsOther
EFFECT: I understand that if HIPAA covered entities and business associates receive these records for treatment, payment, and health care operations purposes, the records may be redisclosed in accordance with HIPAA, except for uses or disclosures for civil, criminal,administrative, or legislative proceedings against me.
Optional: Released information will be relevant to the selected dates only. Note: The exact dates of the documents may fall outside the date range selected
(Optional) from (date)
(Optional) from (date)

MonthDayYear
Date
to (date)

MonthDayYear
Date
OTHER IMPORTANT INFORMATION

1. I do not have to sign this document to get treatment at the Behavioral Health Center unless treatment is required by a court or another official. Some information about me may be given out without my consent if the law allows it. (See Notice of Privacy Practices for more information).
2. This permission will expire in one (1) year from date of signing or when I revoke it in writing. I may take back my permission at any time. I understand the Center cannot take back any information given out before I revoked permission.
3. Copies of this form may be used in place of the original. Signatures received by fax will be accepted.
4. The Center cannot promise that people who get this information will keep it private. They may or may not have to follow the privacy laws. If the information is about substance abuse or HIV/AIDS, the people who get it are not permitted to re-release it to anyone subject to Federal laws.
5. I understand that I am entitled to a copy of this authorization.
6. This Release of Information (ROI) form applies to all Health Solutions programs and locations, including behavioral health and primary care services.
I understand the terms of this consent, and my right to obtain information on the disclosure of my records.
I have been offered a copy of this form.*

Clear
Signature of Patient or Authorized Personal Representative
The person signing this document is:*

PatientAuthorized Personal Representative
Date*

MonthDayYear
Date
If signed by a Personal Representative, please state relationship and authority to consent
I REVOKE the above

Clear
Should be Empty: