Standard Auth

Standard Authorization Form to use and disclose Protected Health Information
I am completing this form to allow the use and sharing of Protected Health Information about: First Name* Last Name*, Date of Birth*
* Name of parent or guardian if the client is under the age of 14: First Name Last Name
1. I authorize Behavioral Healthcare Consultants to use, receive, or disclose the following information:Treatment SummariesHistory Evaluation Report(s) Discharge Summary Medical and/or Medication treatment Progress notes/updates Consultation Recommendations Any related information to psychological/behavioral health Other* if other, please specify
2. Dates of care included: all through 12/31/2024 orwithin the following timeframe:* Date through Date
3. The information will be used/disclosed for the following purposes: continuity/coordination of care responding to family concerns re: treatment referral for medication eval. other* if other, please specify
4. The information will be sent to from Name of person or organization* Street Address* City* State* Zip* Phone Number* Fax Number
Name of client or personal representative:*
Relationship to client
Signature

Clear
Please include your email address in case further information is needed*
I, a healthcare 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. First Name Last Name

Signature of Healthcare Professional

Signature
I do not want a copy of this form
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Standard Authorization Form to use and disclose Protected Health Information