Outside Provider Agency Consent Form

Outside Provider Agency Consent Form
AUTHORIZATION FOR USE, DISCLOSURE, AND/OR EXCHANGE OF MEDICAL & MENTAL HEALTH INFORMATION INCLUDING PRIVATE HEALTH INFORMATION UNDER HIPAA AND CONFIDENTIAL ALCOHOL AND SUBSTANCE ABUSE TREATMENT RECORDS UNDER 42 C.F.R, PART 2
Name*

First NameLast Name
Date

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
NATURE AND LIMITS OF INFORMATION TO BE DISCLOSED:

I hereby authorize Behavioral Health Clinic. to release the following information contained in my provider records, including confidential alcohol and substance abuse treatment records, inclusive of medical, mental health and other identifying information and confidential communications, any medical records and mental health records as described or defined under Maryland statutory or case law, private health information (PHI) under HIPAA, and, if checked off and initialed in the table below, other information 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.

I specifically request the disclosure or non-disclosure of the following information: By electing “Yes” or “No” below, the patient is not admitting to the existence of any said records. Specific Releases:

	Yes	No
Admission and Discharge Dates
Treatment Plans
Diagnosis
Lab Results
Psychiatric Evaluations
Medical Records
Progress In Treatment
Matters Related to Court Orders
Treatment Progress Limitations
Discharge Summary
Attendance
Other

DISCLOSURE TO BE MADE TO/INFORMATION EXCHANGED WITH:

(Include name and phone numbers if known.)
Doctor/psychiatrist: Name Yes No
Circuit Court of: blanks Yes No
Judge: blanks Type option 1 Type option 2
Division of Parole and Probation at: blanks Type option 1 Type option 2
Other: blanks Type option 1 NoType option 2

Purpose of Disclosure:

	Yes	No
Verification of Treatment
Collaboration of Treatment
Obtain Treatment Recommendations
Other:

EXPIRATION DATE/REVOCATION:

This authorization automatically expires one year from the date signed below unless revoked in writing sooner by the individual authorizing disclosure in written form to the person or entity to whom or which the disclosure is or was to be made. Revocation for criminal justice referred substance abuse clients is prohibited pursuant to the conditions of 42 C.F.R. Part 2 §§ 2.31 and 2.35. I understand I can ask the court to limit re-disclosure thereafter.
Redisclosure/Waiver
I also authorize the intended recipient to re-disclose and/or use all or part of the information obtained for purposes of blanks. I understand that the protected information herein may only be re-disclosed to those persons or entities specifically designated herein without further protection under HIPAA, Maryland statutes and federal confidentiality regulations for alcohol and substance abuse under 42 C.F.R. Part 2.
Miscellaneous

A photocopy or facsimile of this authorization and request for release of information shall be deemed as valid as an original. I understand that information may be released in reliance hereon to the extent revocation has not occurred. I understand that benefits may not be conditioned upon signing this authorization.
Signature and Date
Patient Signature

Clear
Date

MonthDayYear
Date
Parent/Legally Recognized Representative Signature

Clear
Date

MonthDayYear
Date
Witness Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Outside Provider Agency Consent Form

AUTHORIZATION FOR USE, DISCLOSURE, AND/OR EXCHANGE OF MEDICAL & MENTAL HEALTH INFORMATION INCLUDING PRIVATE HEALTH INFORMATION UNDER HIPAA AND CONFIDENTIAL ALCOHOL AND SUBSTANCE ABUSE TREATMENT RECORDS UNDER 42 C.F.R, PART 2

NATURE AND LIMITS OF INFORMATION TO BE DISCLOSED:

DISCLOSURE TO BE MADE TO/INFORMATION EXCHANGED WITH:

EXPIRATION DATE/REVOCATION:

Redisclosure/Waiver

Miscellaneous

Signature and Date