Release of Information

Patient Full Name*

First NameLast Name

Date of Birth

Social Security Number

I hereby authorize:*

Methodist Behavioral Hospital (Acute/Sub-Acute()Methodist Children's Home (LR RTC/Dacus RTC/Day Treatment/QRTP/TFCMethodist Counseling Clinic (Outpatient Clinic/School-Based)AR C.A.R.E.S

to disclose and/or to obtain medical records to/from:*

Person or Name of Facility/Clinic (Document address Below if known)

Address for Above Name Person and/or Facility/Clinic:

Address, City, State, and Zip

Document the Contact Person:*

Contact person

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Fax Number

Please enter a valid fax number.Format: (000) 000-0000.

Email Address

example@example.com

Treatment Dates*

Begin Date

Treatment Dates*

To Date

PURPOSE OF DISCLOSURE*

I consent only to the release of information or treatment records as specified below:*

Basic Referral Packet includes; Discharge Information Form, Assessments (All), Physician Discharge Summary, Therapist Discharge Summary, Physician Discharge Orders, History and Physical, Psychiatric Evaluation, Discharge Medication Form, Laboratory Reports, Client Face Sheet, Medication Lists, and Master Treatment Plans:

Pharmacogenetic lab results are to assist in managing the treatment for a current condition, disease, illness, impairment, symptom or disorder. I authorize to release this information*

NOTICE TO RECIPIENTS OF ALCOHOL AND/OR ABUSE SUBSTANCE INFORMATION: This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2). The Federal Rule prohibits you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general 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 abuse patient. I also authorize release of information regarding Alcohol and/or Substance Abuse and HIV/AIDS or other communicable diseases.*

YesNo

Please document the password from the Acute/Sub-Acute or RTC stay (if known)

File Upload-Copy of Photo ID (Drivers License)

I understand that a photocopy of this release will give the same authorization as the original. I understand that once disclosed the information will no longer be private and may no longer be protected by federal privacy laws and regulations. I understand by affixing my name that Methodist may have VERBAL CONTACT with the above-named organization/person. I understand that I may revoke this consent in writing at any time, but such revocation shall have no effect on disclosures previously made. Unless I revoke this authorization prior to its expiration, the authorization to release information will automatically expire ninety (90) days after the patient’s discharge from Methodist, or you may chose ninety (90) days from the date of my signature or other specified date/timeframe. I, the undersigned, understand I am releasing the above information for the stated purpose of my own free will. I understand that by selecting “Yes” in the email address I am consenting that MFH may disclose PHI via encrypted email to the recipient. I attest that this consent was totally completed prior to affixing my signature

90 Days From the Date of My SignatureOther

Print Name of Legal Guardian and Relationship to patient:

Full NameRelationship

Sign signature below.

Staff Signature

By entering the email above I understand I am consenting that MFH may disclose PHI via encrypted email to the recipient.

YesNo

Risks of Using E-mail to Communicate with My Provider: Transmitting patient information by e-mail has a number of risks that I will consider before using e-mail to communicate with the provider. These include, but are not limited to, the following:

E-mail can be circulated, forwarded, and stored in numerous paper and electronic files.
E-mail can be immediately broadcast worldwide and be received by unintended recipients.
E-mail senders can easily type in the wrong e-mail address.
E-mail is easier to falsify than handwritten or signed documents.
Back-up copies of e-mail may exist even after the sender or recipient has deleted his or her copy.
Employers and on-line services have a right to archive and inspect e-mails transmitted through their systems.
E-mails can be intercepted, altered, forwarded, or used without authorization or detection.
E-mail can be used to introduce viruses into computer systems.
E-mail can be used as evidence in court.

Security Measures Taken by Methodist Family Health: Methodist Family Health uses the following security measures among others to ensure the security of protected health information.

Patient-identifiable information is never forwarded to a third party except for treatment, payment, or healthcare operations purposes, without the patient’s express permission.
When necessary to transmit patient-identifiable information via email, the email body and any included attachments are encrypted.
Patient’s e-mail addresses are never used for marketing purposes without the patient’s permission.
Professional e-mail accounts are not shared with the patient’s family members.
E-mails are backed-up and archived on a regular basis.
E-mail recipient addresses are verified prior to sending the message with a confidential indicator attached for the recipient.

Hold Harmless: I agree to indemnify and hold harmless the provider, Methodist Family Health, and its trustees, officers, directors, associates, agents, information providers, suppliers, and website designers and maintainers from and against all losses, expenses, damages, and costs, including reasonable attorney fees, relating to or arising from any information loss due to technical failure, my use of the Internet to communicate with the provider, the use of the provider’s website, any arrangements I make based on information obtained at the site, any products or services obtained through the site, and any breach by me of these restrictions and conditions. The provider does not warrant that the functions contained in any materials provided will be uninterrupted or error-free, that defects will be corrected, or that the provider’s website or the server that makes such site available is free of viruses or other harmful components.

Forwarding E-mails: I understand there may be times in which the provider must forward the information I have provided via e-mail to a third party for treatment, billing, or payment purposes. I expressly provide my consent to allow the provider to forward these e-mails to a third party under these conditions and evidence my consent by signing this form.

Termination of the E-mail Relationship: I have the right to revoke this consent, in writing, at any time by presenting the written revocation to my healthcare provider. The provider shall have the right to immediately terminate the e-mail relationship with me if he or she determines, in his or her sole discretion, that I have violated the terms and conditions set forth in the Agreement or have engaged in conduct which the provider determines to be unacceptable.

Patient Acknowledgement and Agreement: By affixing my signature above I hereby consent to the use of e-mail as a means of communication between a Methodist Family Health provider and me. I have discussed this form with the provider, understand the inherent limitations related to electronic communications, understand the limits of e-mail transactions, hold harmless Methodist Family Health for loss of information due to technical failures, and consent to these conditions and terms.

Authorization/Consent for Release of Information