Non Provider General Consent
AUTHORIZATION FOR USE, DISCLOSURE, AND/OR EXCHANGE OF MEDICAL & MENTAL HEALTHINFORMATION INCLUDING PRIVATE HEALTH INFORMATION UNDER HIPAA AND CONFIDENTIALALCOHOL AND SUBSTANCE ABUSE TREATMENT RECORDS UNDER 42 C.F.R, PART 2
Name of Patient
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
NATURE AND LIMITS OF INFORMATION TO BE DISCLOSED:
I hereby authorize Behavioral Health Clinic (BHC)to release the following information contained in my provider records, including confidential alcohol and substanceabuse treatment records, inclusive of medical, mental health and other identifying information and confidentialcommunications, any medical records and mental health records as described or defined under Maryland statutory orcase law, private health information (PHI) under HIPAA, and, if checked off and initialed in the table below, otherinformation pertaining to my treatment at the above-named facility/provider (all hereinafter collectively “information”).This request authorizes the release, exchange and disclosure of the following information contained in my files. Ispecifically request the disclosure or non-disclosure of the following information.
Admission and Discharge Dates
Yes
No
Attendance
Yes
No
Residential Information
Yes
No
Progress In Treatment
Yes
No
Aftercare Referrals
Yes
No
DISCLOSURE TO BE MADE TO/INFORMATION EXCHANGED WITH:
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PURPOSE OF DISCLOSURE:
Engagement in Treatment
Yes
No
Follow Up Activities
Yes
No
Provide Information about BHC
Yes
No
In Case of Emergency
Yes
No
Treatment Planning Decision
Yes
No
Expiration Date/Revocation
This authorization automatically expires one year from the date signed below unlessrevoked in writing sooner by the individual authorizing disclosure in written form to the person or entity to whom or which thedisclosure is or was to be made. Revocation for criminal justice referred substance abuse clients is prohibited pursuant to theconditions of 42 C.F.R. Part 2 §§ 2.31 and 2.35. I understand I can ask the court to limit re-disclosure thereafter.
REDISLOSURE/WAIVER:
I also authorize the intended recipient to re-disclose and/or use all or part of the information obtainedfor purposes of Continuance of Care. I understand that the protected information herein may only be re-disclosed to those personsor entities specifically designated herein without further protection under HIPAA, Maryland statutes and federal confidentialityregulations for alcohol and substance abuse under 42 C.F.R. Part 2. MISCELLANEOUS: A photocopy or facsimile of thisauthorization and request for release of information shall be deemed as valid as an original. I understand that information may bereleased in reliance hereon to the extent revocation has not occurred. I understand that benefits may not be conditioned upon signingthis authorization.
Patient Signature
Clear
Date
-
Month
-
Day
Year
Date
Parent/Legally Recognized Representative Sign.
Clear
Date
-
Month
-
Day
Year
Date
Witness Signature
Clear
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: