AUTHORIZATION FOR USE AND DISCLOSURE OF INFORMATION
Name of Client (Please Print) / Date of BirthPhone No.: / Dragon ID:
I authorize verbal and/or written exchange about my information between these two parties:
Minnesota State University Moorhead
Hendrix Clinic and Counseling Center
1104 7th Avenue South, Box 92
Moorhead, MN 56563 /
SPECIFIC DESCRIPTION OF INFORMATION TO BE USED AND DISCLOSED
(Specify dates for each, unless “entire medical records” is selected)_____Hendrix treatment from ______(date) to ______(date)
_____All Medical Records _____ Psychiatric Assessment/Consultation
_____Discharge Summary _____ Chemical Dependency Evaluation
_____Progress Notes _____ Medical or Lab Reports (specify)______
_____Psychological Assessment/Consultation _____ Other (specify)______
I AUTHORIZE RELEASE OF ALL ALCOHOL AND/OR DRUG ABUSE RECORDS THAT ARE PART
OF THE RECORDS I SPECIFIED ABOVE, UNLESS OTHERWISE INDICATED HERE:
_____Do not release records from alcohol or drug abuse treatment programs that are protected under federal law.
Notice to recipients of information disclosed from alcohol or drug abuse treatment records protected by Federal confidentiality rules (42 CFR part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by 42 CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.
PURPOSE OF THE USE AND DISCLOSURE
_____ Planning and/or continuing my care and treatment _____ Personal Use_____ Legal _____ Student Conduct
_____ Appeals Committee/Reference: ______Other (specify)______
_____ Determining reasonable accommodations for educational services
I authorize the use and disclosure of my individually identifiable health information as described above. I understand that this authorization is voluntary. I understand that if the person or organization I authorize to receive the information is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations and could be re-disclosed. I understand that my health care and payment for my health care will not be affected if I do not sign this form. I understand that I may have a copy of this release upon request.
I understand that I may revoke this authorization in writing at any time, except to the extent action has already been taken in reliance on it. I understand that this authorization will expire on:______(specify date or event) or, if no date or event is specified, 12 months from the date of signing.
A photocopy or fax of this authorization will be treated in the same manner as the original.
Instructions for signing: Generally, the adult client (or legal representative) or the parents (guardians) of minors should sign the authorization to Release Information. The Minor’s Consent for Medical Treatment Act allows some minors, under certain circumstances, to sign an authorization without parent(s) or guardian(s) consent. The signature of a minor should be witnessed by a staff person (adult).
Client’s Signature / Date
Street / City / State / Zip
Signature of Witness / Date / Parent/Guardian Signature / Date
NOTICE TO PROVIDERS: The information you provide pursuant to this release may be viewed by the client unless you specify in writing the statutory basis for withholding the information from the client.
Information Sent:
Mode of Transmittal: Telephone _____ Fax _____
Mail_____ Electronic_____ /