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Outside Provide Agency Consent Form

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Outside Provider Agency Consent Form

 

AUTHORIZATION FOR USE, DISCLOSURE, AND/OR EXCHANGE OF MEDICAL & MENTAL HEALTH INFORMATION INCLUDING PRIVATE HEALTH INFORMATION UNDER HIPAA AND CONFIDENTIAL ALCOHOL AND SUBSTANCE ABUSE TREATMENT RECORDS UNDER 42 C.F.R, PART 2

 

Name

NATURE AND LIMITS OF INFORMATION TO BE DISCLOSED:

I hereby authorize Behavioral Health Clinic. to release the following information contained in my provider records, including confidential alcohol and substance abuse treatment records, inclusive of medical, mental health and other identifying information and confidential communications, any medical records and mental health records as described or defined under Maryland statutory or case law, private health information (PHI) under HIPAA, and, if checked off and initialed in the table below, other information pertaining to my treatment at the above-named facility/provider (all hereinafter collectively “information”). This request authorizes the release, exchange and disclosure of the following information contained in my files.

I specifically request the disclosure or non-disclosure of the following information: By electing “Yes” or “No” below, the patient is not admitting to the existence of any said records. Specific Releases:
YesNo
Admission and Discharge Dates
Yes
No
Treatment Plans
Yes
No
Diagnosis
Yes
No
Lab Results
Yes
No
Psychiatric Evaluations
Yes
No
Medical Records
Yes
No
Progress In Treatment
Yes
No
Matters Related to Court Orders
Yes
No
Treatment Progress Limitations
Yes
No
Discharge Summary
Yes
No
Attendance
Yes
No
Other
Yes
No

DISCLOSURE TO BE MADE TO/INFORMATION EXCHANGED WITH:

(Include name and phone numbers if known.)

Purpose of Disclosure:
YesNo
Verification of Treatment
Yes
No
Collaboration of Treatment
Yes
No
Obtain Treatment Recommendations
Yes
No
Other:
Yes
No

EXPIRATION DATE/REVOCATION:

This authorization automatically expires one year from the date signed below unless revoked in writing sooner by the individual authorizing disclosure in written form to the person or entity to whom or which the disclosure is or was to be made. Revocation for criminal justice referred substance abuse clients is prohibited pursuant to the conditions of 42 C.F.R. Part 2 §§ 2.31 and 2.35. I understand I can ask the court to limit re-disclosure thereafter.

Redisclosure/Waiver

I understand that the protected information herein may only be re-disclosed to those persons or entities specifically designated herein without further protection under HIPAA, Maryland statutes and federal confidentiality regulations for alcohol and substance abuse under 42 C.F.R. Part 2.

Miscellaneous

A photocopy or facsimile of this authorization and request for release of information shall be deemed as valid as an original. I understand that information may be released in reliance hereon to the extent revocation has not occurred. I understand that benefits may not be conditioned upon signing this authorization.

Signature and Date

Clear Signature
Clear Signature
Clear Signature

Presets Color

Primary
Secondary
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