Sample Release Of Information Form Mental Health

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State laws may also protect the condentiality of the clients records. 9 sample release of information forms.

Michigans integrated mental health substance abuse and primary care services confidentiality policy provides a useful sample for other states review.

Sample release of information form mental health. It defines what information are to be released for what purpose and when is the expiry date of the form. If i am authorizing the release of hivaids related alcohol or drug treatment or mental health treatment information the recipient is prohibited from redisclosing such information or using the disclosed information for any other purpose without my authorization unless permitted to do so under federal or state law. A non complying release of information form is acceptable when the request is from and for another providers treatment payment or operations activities.

I authorize the release of my complete health record including records relating to mental healthcare communicable diseases hiv or aids and treatment of alcohol or drug abuse. You also have the right to review the information you give us on the form. 42 cfr resources the legal action center developed a series of tools to help organizations navigate the 42cfr part 2 rules for confidentiality around drug and alcohol use.

I authorize the release of my complete health record with the exception of the following information. Release of information form this template can be used to coordinate the release of confidential information during a clients transition of care or other cicrumstances where private records need to be shared. Disclosure is limited to the purpose and persons included on the authorization form.

To the individual filling this out. The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. It is also acceptable for releasing information for treatment payment and operations purposes covered under the hipaa consent provision.

Sample standard authorization for disclosure of mental health treatment information i insert name of patientclient whose date of birth is authorize insert name of mental health counseling organization to disclose to andor obtain from. You have a detailed release of information form here that pertains to the release of details regarding the mental health of a person. You have the right to ask us about this form.

The release of information form is used when you are going to submit a written request to a body an organization your insurance provider your work organization or some government body to release some information.