inforelease

Delta Psychological & Neurobehavioral Services
114 Tuscola Rd.; Bay City, Michigan 48708
(989) 895-0788; (989) 895-0799 (fax)

INFORMATION RELEASE AUTHORIZATION
(Name of client)*
Date of birth*

MonthDayYear
Date
I authorize Delta Psychological & Neurobehavioral Services to disclose to and/or obtain from:
The following information:

Description of Information to be Disclosed/Obtained:
Type a question

AssessmentDiagnosisPsychosocial EvaluationPsychological EvaluationPsychiatric EvaluationTreatment Plan or SummaryCurrent Treatment Update
Type a question

Presence/Participation in TreatmentDischarge/Transfer SummaryContinuing Care PlanProgress in TreatmentDemographic InformationMedication Management InformationOther
Purpose The purpose of this disclosure of information is to improve assessment and treatment planning, share information relevant to treatment and when appropriate, coordinate treatment services. If other purpose, please specify:
If other purpose please specify
Revocation

I understand that I have a right to revoke this authorization, in writing, at any time by sending written notification to Delta Psychological & Neurobehavioral Services. I further understand that a revocation of the authorization is not effective to the extent that action has been taken in reliance on the authorization.

Expiration

Unless sooner revoked, this consent expires on the following date: Or as otherwise indicated:
MonthDayYear
Date
Or as otherwise indicated
Conditions

I further understand that Delta Psychological & Neurobehavioral Services will not condition my treatment on whether I give authorization for the requested disclosure. However, it has been explained to me that failure to sign this authorization may have the following consequences:
Consequences:
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

Federal law prohibits the person or organization to whom disclosure is made from making any further disclosure of substance abuse treatment information unless further disclosure is expressly permitted by the written authorization of the person to whom it pertains or as otherwise permitted by 42 CFR part 2.

Other than substance abuse treatment information, there is the potential that the protected health information that is disclosed pursuant to this authorization may be redisclosed by the recipient and the protected health information will no longer be protected by the HIPAA privacy regulations.

A copy of this authorization will be given to the client or designated representative.
Signature of Client/Parent/Guardian/Personal Representative*

Clear
Date*

MonthDayYear
Date
Signature of Staff Witness

Clear
Date

MonthDayYear
Date
Signature of Staff Witness DPNS Rev. 9/13
Should be Empty: