Practice Name, Address, Telephone Number

Authorization to Obtain/Release Medical/Psychiatric/Substance Abuse Information

Patient: ______Date of Birth:______

Patient’s Address:______SS #______

I hereby authorize: ______to (check one)Obtain from Release to

Facility/Name: ______

Address: ______

______

Attention:______

Telephone (if available) :______FAX (if applicable)______

As stated above, please [obtain from or release to] the following checked information contained in the medical/psychiatric/substance abuse record in the above named patient pertaining to services provided on [or about or date range] ______.

Authorization does not include psychotherapy notes, information

Please check the appropriate information to be released:protected under Fed. Reg. 42 CFR Part II or HIV information

All records [or specify below]unless authorized below.

Physical Exams Chart Notes Consults Psychological Testing(s)

Treatment PlansProgress in Treatment Admission Notes Assessments

 Labs X-rays or reports Discharge Summaries Bio-psychosocial History

Other: Please specify.______

  • I understand that treatment and coverage is not based upon my signing this authorization. The information is needed for the following purpose(s).

 To provide ongoing treatment/aftercare. At the request of the patient (or parent or legal guardian)

 Other: ______

  • I understand this authorization is subject to revocation at any time unless action based on it has already begun. Requests for revocation will be done in writing. The authorization expires 90 days from the date of signature.
  • I understand that the information may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law.
  • I further release the persons and/or agencies named above from any liability arising from the release of this information to such persons and/or agencies, provided the said release of information is done substantially in accordance with applicable law.

 I DO  I DO NOT agree that a copy of this form is as valid as the original.

Date: ______Signature of Patient: ______

Signature of legal guardian or parent of patient under 18: ______/______

Relationship to patient

Please check the appropriate statements: (If not applicable, leave blank.)

 I DO  I DO NOT authorize disclosure of information which refers to treatment or diagnosis of drug or substance abuse which I understand is protected by Federal Regulation: 42 CFR Part II.

Signature:______Date:______

 I DO  I DO NOT authorize the release of psychotherapy notes. Signature:______Date:______

I have carefully read and understand the above statement and do herein expressly and voluntarily consent to disclosure of information and/or psychiatric records including Alcohol and Drug Abuse information, if applicable, about my condition and treatment to those persons/agencies named above, provided a release of information is done substantially in accordance with applicable laws.

AUTHORIZATION TO RELEASE H.I.V. INFORMATION

I hereby specifically authorize the release of HIV (HTLV III) antibody or antigen testing or records containing HIV, HIV virus or any AIDS related conditions which may be contained in the above referenced request.

Date:______Signature: ______

Copy to patient and patient’s chart