KENNEBECBEHAVIORALHEALTH
736OLDLEWISTONRD,WINTHROP,ME04364-PHONE:(207)377-8122-FAX:(207)377-8560AUTHORIZATIONTORELEASEPROTECTEDHEALTHINFORMATION
File/Send
Name:(first,middleinitial,last) ID:DateofBirth: Phone:
IherebyallowKBH,itsapprovedstafforagentstoreleasemyProtectedHealthInformationasoutlinedbelow.
(Checkallapproveditems)
Give,GetandDiscussRecordsandInformationwith:GetRecordsandInformationFrom:GiveRecordsandInformationTo:DiscussRecordsandInformationWith:
Organization/PrimaryContact:
Relationship:Phone:
Fax:
Address: City: State: Zipcode:
(A)TheperiodforwhichinformationisrequestedisFrom:To:
(B)Thespecificinformationtobereleasedis:Allinformationbelow
DischargeSummary
LabReports
Medications
TreatmentHistory
DSMDiagnosis
InitialEvaluation/AssessmentOther:
PsychiatricEvaluation(s)Psychological Assessment(s)/Testing
MedicalHx/PhysicalTreatmentPlan(s)ProgressNotes
(C)Thereasonforthereleaseofthisinformationis:
AssistwithEvaluation/AssessmentCoordinationofServices
TreatmentPlanningOther:
JudicialProceedings
(D)IfIhavebeendiagnosedortreatedforanyofthefollowing,Iunderstandthatmyspecificconsenttodiscloserelatedinformationisnecessary.(Mustpickanoptionforeachofthethreequestionsbelow.)
IDoDoNot
authorizedisclosureofinformationwhichreferstotreatmentordiagnosisofdrugoralcoholabuse.Suchinformationmaynotbere-disclosedbytherecipientwithoutmyspecificwrittenconsent.
IDo
IDo
DoNotDoNot
authorizedisclosureofinformationwhichreferstomentalhealth/psychiatrictreatmentordiagnosis.authorizedisclosureofinformationthatreferstotreatmentordiagnosisofHIV.
(E)
Iwishtolookattheinformationbeforeitisreleased. Thisreviewmustbedocumented.
(F)Iagreetothefuturereleaseofinformationtotheaboveperson/organizationduringtheapprovedtimeperiod.
(G)ThisagreementtoreleaseinformationhasanIunderstandthat:
ExpirationDateof:.Thisdatecanbenolongerthan12months.
•IcantakebackthisapprovalatanytimebymakingarequestinwritingtoKBHRecordRoomormyserviceprovideratKBH.
StoppingthisReleaseofInformationwillnotaffectanyinformationreleasedbeforeItookawaymyapproval. Takingawaymyapprovaltoreleaserecordscouldresultinimproperdiagnosis,impropertreatment,anddenialofinsurancecoverageorhaveothernegativeconsequences.
•Icanrefusetoreleasesomeorallofmyrecords. However,suchrefusalsmayresultinimproperdiagnosis,impropertreatment,anddenialofinsurancecoverageorhaveothernegativeconsequences.
•KBHcannotcontrolpeopleororganizationsreceivingthisinformationtopreventre-releaseofitwithoutmyapproval.
•IcancrossoutanycheckedoffitemIdonotagreewith. Imayhaveacopyofthisformuponrequest.
SIGNATURE:DATE:
Client/GuardianorOtherAuthorizedPerson'sSignature
WITNESS:DATE:
ForPersonsorOrganizationsreceivingSubstanceAbuseorMentalHealthInformation:
Thisinformationhasbeendisclosedtoyoufromrecordswhoseconfidentialityisprotectedbyfederallaw. Federalregulations(42CFR,Part
2)prohibityoufrommakinganyfurtherdisclosureofitwithoutthespecificwrittenconsentofthepersontowhomitpertains,orasotherwisepermittedbysuchregulations. Ageneralauthorizationforthereleaseofmedicalorotherinformationisnotsufficientforthispurpose. Thefederalrulesrestrictanyuseoftheinformationtocriminallyinvestigateorprosecuteanyalcoholordrugabuseclient(52FR21809:52FR41997).
ThisinformationhasbeendisclosedtoyoufromrecordswhoseconfidentialityisprotectedbyStateConfidentialityLaws(34MRSASection1207;RightsofRecipientsofMentalHealthServices).Thisinformationremainsconfidentialandshouldnotbedisclosedanyfurtherexceptasexpresslypermittedbythewrittenconsentofthepersontowhomitpertainsorasotherwisepermittedbylaw.
Totakebackthisapproval,completetherevocationsectionbelow.
REVOCATION
Iunderstandthatitismyrighttotakebackthisauthorizationatanytime. Ihavebeeninformedofthepotentialconsequencesresultingfrommytakingbackthisauthorization. Ifurtherunderstandthattakingbackthisreleasewillnotaffecttheinformationalreadyreleasedasaresultofmyoriginalapprovaltodosobutunderstandthatallfuturereleasesofthisinformationwillnotbeallowedafterthedatebelow.
RevocationofAuthorization:DATE: ______
Client/GuardianorOtherAuthorizedPerson'sSignature
WitnessSignature:DATE: