Creative Solutions

Authorization to Use and Disclose Protected Health Information

1. I am completing this form to allow the use and sharing of protected health information about

Printed name: _____________________________ Date of Birth: ___________

2. I authorize this person or organization _______________________________ 

________________________________________________________________

________________________________________________________________

3a. To use or disclose the following information:

  Inpatient or outpatient treatment records for physical and or psychological, psychiatric, or    

emotional illness or drug and/or alcohol abuse.

  Admission and discharge summaries

  Psychological or psychiatric evaluation(s), reports, assessments, treatment notes, summaries, or other documents with diagnoses, prognoses, recommendations, or testing records, and behavioral observations or checklists completed by any staff member or the patient, or similar documents.

  Treatment, recovery, rehabilitation, aftercare plans and other similar plans.

  Social, family, educational, and vocational histories

  Social work assessments and plans

  Progress, nursing, case or similar notes.

  Evaluations and reports of consultants

  Information about how the patient's condition(s) affects or has affected his or her ability to

work, and to complete tasks or activities of daily living.

  Vocational evaluations and reports

  Billing records

  Academic and educational records, including achievement and other tests' results, reports of teachers' observations, and all other school or special eduation documents

  HIV-related information and drug and alcohol information contained in these records will be     released under this authorization unless indicated here 

              

Do not release these:

Complete copy of the medical record.

Other: _________________________________________________________

3b. Dates of care included: From ______________ to _________________ and

From ______________ to ______________________ and

From ______________ to ______________________

4.  To this person or organization           

_______________________________________________________________

_______________________________________________________________

                                            (when printed, another page follows)

5.  The information will be used/disclosed for the following purposes:

_______________________________________________________________

_____________________________________________________________

6.  I understand and agree that this Authorization will be valid and in effect until

______________________________________________ [Enter a date or event upon which this Authorization expires.] I understand that after that date or event, no more of this information can be used or released to the person or organization unless I sign a new Authorization like this one. 

7. I understand that I can revoke or cancel this authorization at any time by sending a letter to the Privacy Officer of the organization listed above and which is to supply this information. If I do this, it will prevent any releases after the date it is received but can not change the fact that some information may have been sent or shared before that date.

8. I understand that I do not have to sign this authorization and that my refusal to sign will not affect my abilities to obtain treatment from the professional or facility listed at number 4 above, nor will it affect my eligibility for benefits. 

9. I understand that I may inspect and have a copy the health information described in this authorization.

10. I understand that if the person or entity that receives the information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be redisclosed and no longer protected by those regulations.

11. I affirm that everything in this form that was not clear to me has been explained and I believe I now understand all of it. 

_______________________________________________          ______________

Signature of client or his or her personal representative               Date

12. __________________________________________              ______________________

Printed name of client or personal representative        Relationship to the client

________________________________________________________________

Description of personal representative's authority

13. I acknowledge that I received a copy of this completed form 

_________________________________________________        _____________

Signature of client or his or her personal representative       Date

14. I, a mental health professional, have discussed the issues above with the client and/or his personal representative. My observations of his or her behavior and responses give me no reason to believe that this person is not fully competent to give informed and willing consent

_________________________      ______________________________     ________

Signature of professional      Printed name of professional.                Date