Authorization for use or disclosure of Protected Health Information

Client Information

 

Client Last Name_______________________ First Name _________________MI ___ DOB:___/___/____

​

Client Address: _________________________________________________________________________

Client Home Phone: ___________________________

Cell/Work Phone: _____________________

Client Email Address: ____________________________________

 

Recipient Information

I, _________________________, do hereby authorize __________________________ to release a copy of my mental health information to the person or facility below.

 

Name of person/facility to receive medical information: _______________________________ Phone: ________________________

Address: ______________________________________________________________________

 

Date of Authorization: ___/___/______

Authorization to expire on ___/___/______ or upon the happening of the following event: _____________________________________________________________

 

 

__________________________________________________________________________________ 

Information to be Released (Note: Requests for release of psychotherapy notes cannot be combined with any other type of request.)

 ___ My entire mental health record

 ___Only those portions pertaining to: ______________________________________________________ (Specific provider name and/or dates of treatment)

 ___ Authorization for Psychotherapy Notes ONLY (Important: If this authorization is for Psychotherapy Notes, you must not use it as an authorization for any other type of protected health information.)

 Other: __________________________________________________________________________________

 

Purpose of Information Release:

___ Further mental health care

___ Payment of insurance claim

___ Legal investigation

___ Applying for insurance

___ Vocational rehab, evaluation

___ Disability determination

___ At the request of the individual

___ Other (specify): ____________________________________

​

​

Authorization and Signature

I authorize the release of my confidential protected health information, as described in my directions above. I understand that this authorization is voluntary, that the information to be disclosed is protected by law, and the use/disclosure is to be made to conform to my directions. The information that is used and/or disclosed pursuant to this authorization may be re-disclosed by the recipient unless the recipient is covered by state laws that limit the use and/or disclosure of my confidential protected health information.

 

 

_________________________________________ ___________________

Signature                                                                 Date

​

If signed by a personal representative:

(a) Print your name: _______________________________________________

(b) Indicate your relationship to the client and/or reason and legal authority for signing:

 

Patient is:

___ minor

___  incompetent

___ disabled

___ deceased

 

Legal authority:

___  parent

___ legal guardian

___ representative of deceased