BESST Release

BESST Multi-Agency Consent for the Release of Confidential Information
The purpose of this form is to allow me to choose how my services are coordinated. I understand that this is my decision to make and that I can change my mind. If I change my mind, I need to make a written request to cancel this consent. This request will go to the agency or program’s Medical Record or Health Information Department for processing. I also understand that I can ask a staff member to assist me with this process. If I have a legal guardian, my guardian may sign or cancel this consent on my behalf.

For any questions, please contact:

Lauri Murphy, MSW - BESST Coordinator

The Pettengill House, Inc.

Direct: (978) 243-9746 | Main Office: (978) 463-8801

lmurphy@pettengillhouse.org
Name*

First NameLast Name
Date of Birth*

MonthDayYear
DOB
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please check off the providers with whom you would like to allow communication and exchange of information needed to coordinate and continue care, treatment and services. By leaving a box unchecked, you are stating that you do not want information communicated or exchanged with that provider.*

Anna Jaques HospitalLink House, Inc.The Pettengill House, Inc.Lahey Behavioral HealthCataldo/Atlantic AmbulanceEssex County OutreachPolice DepartmentCouncil on AgingJeanne Geiger Crisis CenterNone of the AboveOther
Please list any additional agencies with whom you would like to allow your information to be communicated and exchanged:
Please specify which type(s) of information you would like to allow to be communicated with the providers checked off or listed above:
Demographic Information*

YesNo
Assessments*

YesNo
Physical Exam*

YesNo
Treatment Plan*

YesNo
Treatment Notes*

YesNo
Medications*

YesNo
Admit/Discharge Summary*

YesNo
Lab/X-ray Reports*

YesNo
Housing Information*

YesNo
Please specify any additional information you would like to allow to be communicated with the providers checked off or listed above:
Date, event, or condition when consent expires (in the event no date/event/or condition is specified, this consent expires one year from the date of signing):
I understand that treatment services are NOT contingent upon or influenced by my decision to permit the information release.

I understand that the information and records disclosed pursuant to this consent may be protected under 42 CFR Part 2, governing Alcohol and Drug Abuse patient records, the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and 45 CFR parts 160 and 164, State Confidentiality laws and regulations, and cannot be released without my consent unless otherwise provided for by the regulations. State and Federal regulations prohibit any further disclosure of such information and records without my specific written consent unless otherwise permitted by such regulation.

The information I authorize for release may include records that may indicate the presence of a communicable or venereal disease, which may include, but is not limited to diseases such as hepatitis, syphilis, gonorrhea, and the human immunodeficiency virus, also known as acquired immune deficiency syndrome (AIDS).
Signature*

Clear
Date*

MonthDayYear
Date
Signature of legal guardian, if required

Clear
Date

MonthDayYear
Date
Relationship to consumer
Should be Empty:

BESST Multi-Agency Consent for the Release of Confidential Information