Release of Information Authorization for Disclosure of Mental Health Treatment Information

Release of Information Authorization for Disclosure of Mental Health Treatment Information
Patient Name
DOB

Month Day Year
Date
Phone
I AUTHORIZE THE DISCLOSURE OF MY HEALTH INFORMATION BETWEEN BOTH PARTIES INDICATED BELOW.
Please indicate if Lansing Institute of Behavioral Medicine is sending the information or receiving information by checking below:

Sending Receiving
Provider Name
Lansing Institute of Behavioral Medicine

3475 Belle Chase Way

Lansing, MI 48911

Phone: 517-882-3732

Fax: 517-882-3633
Please indicate if the Medical Office/Attorney/Workplace/Govt/Agency/Individual/Other is sending or receiving the health information:

Sending Receiving
Business Name
(Name of Medical Office/Attorney/Workplace/Govt Agency/Individual/Other)
Business Address

Street Address Line 2
Business City, State, Zip Code

Street Address Line 2
Business Phone
Business Fax
Description of Information to be Disclosed

Initial those that apply
Diagnosis Only
Medication Information Only
Appointment Attendance Document
Diagnostic Psychological Interview
Diagnostic Psychological Interview
Treatment Summary
FMLA Paperwork
Long Term/Short Term Disability Paperwork
Entire Medical Record
Medical Records ONLY between specific dates
(Select dates below)
From

Month Day Year
Date
To

Month Day Year
Date
Purpose

This information may be used or disclosed in connection with mental health treatment, payment, or healthcare operations. Please specify the purpose for the disclosure below:
Coordination of Care
Transfer of Care
At the Request of the Individual
Conditions

A request for disclosure of health information may include information regarding drug, alcohol or mental health treatment, social service records, communications made to a social worker and information regarding serious communicable diseases and infections as defined by the Michigan Department of Public Health Code, which includes venereal disease, tuberculosis, acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV I understand that my records are protected under the applicable state law governing health care information and that relates to mental health services and under the federal regulations governing Confidentiality of Alcohol and Drug Abuse Patients Records 42 CRF Part 2 and cannot be disclosed without my written consent unless otherwise provided for in state or federal regulations.

I further understand that Lansing Institute of Behavioral Medicine will not condition my treatment, payment, enrollment, or eligibility for benefits on whether I give authorization for the requested disclosure. However, it has been explained to me that failure to sign this authorization will result in Lansing Institute of Behavioral Medicine not being permitted to release/disclose any of my information.
Revocation

I understand that I have a right to revoke this authorization, in writing, at any time by sending written notification to Medical Records Department at Lansing Institute of Behavioral Medicine at the address above. I further understand that revocation of the authorization is not effective to the extent that action has been taken in reliance on the authorization.
Form of Disclosure

Unless you have specifically requested in writing that the disclosure be made in a certain format, we reserve the right to disclose information as permitted by this authorization in any manner that we deem to be appropriate and consistent with applicable law, including, but not limited to, verbally, in paper format or electronically.
Re-disclosure

I understand that there is the potential that the protected health information that is disclosed pursuant to this authorization may be redisclosed be the recipient and the protected health information will no longer be protected by the HIPAA privacy regulations, unless a State law applies that is more strict than HIPAA and provides additional privacy protections.
Expiration

Unless sooner revoked, this authorization expires 6 months from the date of signature or as otherwise indicated here:
Date

Month Day Year
Date
Signature of Patient/Client

Clear
Date

Month Day Year
Date
Signature of Parent, Guardian, or Personal Representative

Clear
Date

Month Day Year
Date
If you are signing as the personal representative of an individual, please describe your authority to act for this individual
Signature of Staff Witness

Clear
Date

Month Day Year
Date
I have the option to request a copy of this authorization for my records
Should be Empty: