Release of Information

Release of Information

MySpectrum
Patient Name*

First NameLast Name
Patient Name:*
Date of Birth:*

MonthDayYear
Date
I hereby authorize MySpectrum Counseling & Coaching (MSCC) staff to discuss the aforementioned patient's information with:*
Name of person or organization to contact regarding patient care.
If you are seeing a specific clinician at the location above, please list their name here. If not write "N/A".*
Contact information for party that MySpectrum Counseling and Coaching staff will correspond with (phone #, fax #, or address, N/A if unknown):*
If you do not know the person or office's contact information this may result in a delay or inability to contact them.
I hereby authorize MySpectrum Counseling & Coaching (MSCC) staff to interact with the above in the following way:*

Disclose informationObtain informationExchange information
The information may include (check all that apply):

Medical RecordsEducational / Academic RecordsPsychiatric EvaluationOngoing exchange of informationNeurological ExamBehavioral ReportsTeacher ReportsSubstance Abuse EvaluationVerbal exchange re:client historyOther
I understand that the purpose of this disclosure is for CLIENT TREATMENT COLLABORATION.

I understand that I am giving permission to disclose, release and/or obtain protected health information. Any eligibility for benefits, treatment, payment, or enrollment is not affected by this release of information. Such information may be subject to re-disclosure by the recipient and will thus no longer be protected by the Health Insurance Portability and Accountability Act (HIPAA) privacy regulations and may not be protected by state law.

I further understand that I may decline to sign this form. I also understand that I may revoke this consent to disclose information at any time. If I choose to revoke this consent, I must do so in writing. The authorization will remain in effect for one (1) year.
Client/Representative Name:*
Client/Representative Signature:*

Clear
Date:*

MonthDayYear
Date
The above signing individual certifies that he/she is*

SelfGuardianOther
Note: This information may be protected by federal regulations concerning alcohol and drug abuse patient records. (42 CFR, Subchapter A, Part 2), which prohibit a recipient from making any further disclosure of alcohol or substance abuse treatment information unless expressly permitted by the written authorization of the person to whom it pertains or as otherwise permitted by such regulations. These regulations also restrict any use of information to criminally investigate or prosecute 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 patient.
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