AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION
MATRIX HEALTH SYSTEMS
Client Name
*
First Name
Last Name
I authorize
Provider Name
*
to:
*
Release to
Obtain from
Name of Person or Agency:
*
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Dates of Treatment
From:
-
Month
-
Day
Year
Date
To:
-
Month
-
Day
Year
Date
Mental Health Record information permitted to be obtained or released:
My mental health/health record history in its entirety
Medications
Treatment recommendations
Progress notes
Diagnosis/assessment
Other
If you selected other, please describe:
Substance Abuse Record information permitted to be obtained or released:
My substance abuse record in its entirety
Substance abuse evaluation
Treatment recommendations
Progress notes
Medications
Other
If you selected other, please describe:
This authorization will expire one year from the date signed below, unless sooner revoked in writing, OR upon the date, event or condition noted below:
This information will be used and disclosed for the following purpose(s):
Treatment planning
Continuity of care
Diagnosis and assessment
Other
If you selected other, please describe:
Client Signature:
Date:
-
Month
-
Day
Year
Date
Personal Representative (if applicable):
First Name
Last Name
Describe Personal Representative Relationship (parent, guardian, etc.)
Personal Representative Signature:
Date:
-
Month
-
Day
Year
Date
Continue
Continue
Should be Empty: