MPW_ROI_RELEASE FORM FOR MOBILE

Consent for the release of Confidential Health Information under 42 C.F.R PART 2 - Confidentiality of Alcohol and Drug Abuse Patient Records
Age
Today's Date

MonthDayYear
Date
Client Name*

First NameLast Name
Date of Birth:*

MonthDayYear
I,   First Name*   Last Name*, authorize Modern Psychiatry and Wellness to release/exchange information with Person/Organization Name*

Area Code*   Phone Number*      Fax Number
Type of information to be disclosed:*

AttendanceToxiologyMedication(s)/dosingAssessments/DiagnosisProgress in TreatmentTreatment PlansLab ResultsAppointmentsInsurance/DemographicsDischarge SummaryOther
*By signing below, I understand the information above, to be released or disclosed, may include information relating to my mental health information and/or drug and alcohol use, sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), and/or human immunodeficiency virus (HIV).
PATIENT SIGNATURE:

Clear
Date*

MonthDayYear
Date
PARENT/GUARDIAN SIGNATURE:

Clear
Date

MonthDayYear
Date
For the purpose of*

Continuity of CareCoordinating TreatmentEmergency ContactPaymentLegalOther
I understand that my alcohol and/or drug abuse treatment records are protected under federal regulations 42 C.F.R PART 2 - Confidentiality of Alcohol and Drug Abuse Patient Records and cannot be disclosed without my written consent. I do not need to sign this form to obtain treatment and I understand that if I do not sign this authorization MPW will not condition treatment, payment, enrollment, or eligibility and there will be no consequences. I may revoke this consent in writing at any time. I understand that the revocation will not be effective retroactively for information disclosures that have already occurred. If not previously recorded. this consent will terminate either: In one year from the date of signature below or 90 days after discharge (whichever comes first) OR Upon a specific date, event or condition listed here: Type a label Date
PATIENT SIGNATURE First Name* Last Name* Date of Birth* Signature* Date*

Parent/Guardian Signature Date
*If the individual is unable to sign due to legal incapacity, the signature of the individual's personal representative is required. Documentation of the personal representative's legal authority must be attached. If applicable, indicate whether proof of legal authority was obtained by staff

YesNo
Personal Representative Printed Name:

First NameLast Name
Relationship to Patient
Signature of Personal Representative:

Clear
Date

MonthDayYear
Date
TO REVOKE RELEASE:

By signing below, I am revoking this Consent for the Release of Confidential Health Information.
Patient Revocation Signature

Clear
Date

MonthDayYear
Date
NOTICE OF RECIPIENT OF INFORMATION

This information has been disclosed to you from records protected by federal confidentiality rules (42 CFR part 2). The federal rules prohibit you from making further disclosure of information in this record that identifies a patient as having or having had a substance use disorder either directly, by reference to publicly available information, or through verification of such identification by another person unless further disclosure is expressly permitted by written consent of the individual whose information is being disclosed 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 (see 2.31). The federal rules restrict any use of the information to investigate or presecute with regard to crime any patient with substance use disorder, except provided at $$ 2.12(c)(5) and 2.65.
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Consent for the release of Confidential Health Information under 42 C.F.R PART 2 - Confidentiality of Alcohol and Drug Abuse Patient Records

TO REVOKE RELEASE: