Authorization for Release of Mental Health, Alcohol & Drug Abuse, and Other Personal Health Information

Authorization for Release of Mental Health, Alcohol & Drug Abuse, and Other Personal Health Information
I,   First Name   Last Name   , hereby authorize The Center for New Pathways to exchange/release any and all records or information regarding   First Name   Last Name      Specific nature of information to be disclosed.

The following items must be checked and initialed to be included in the use and/or disclosure of other health information:
Mental Health Information    Initials
Psychotherapy Notes   Initials
Drug/alcohol diagnosis, treatment/referral   Initials
to   Receiving Agency/person  Address

For the purpose of: (please check all that apply)
Continuing (health and mental health)
Therapist transition
Housing and other arrangements and services   Billing, payment and financial matters and arrangements   Consultation, advice and representation regarding my condition and needs
Other

This consent is valid until   Date    .

I understand that I have the right to inspect and copy the information to be disclosed and may revoke this authorization at any time. Any such revocation will not affect materials disclosed prior to the revocation. The above-named person authorized to receive this information may use the information only for the purposes outlined above and may not redisclose it without my written authorization.

I also understand that if I refuse to consent to this release of information the following may occur: Nothing.
Minor recipient, 12-17 yrs. Inclusive

Clear
Signature of adult patient or parent

Clear
Date

MonthDayYear
Date
Witness

Clear
Notice to Patient and Receiving Agency:

Under the provisions of the Illinois Mental Health and Developmental Disabilities Confidentiality Act, HIPAA, and applicable Federal and State Alcohol and Substance Abuse Confidentiality Acts, there may not be redisclosure of any of the information provided pursuant to this release unless the patient, and/or parent of the patient who is a minor, specifically authorizes such disclosure. A separate release is required for psychotherapy notes.
Revocation of Authorization

The undersigned hereby revokes the above authorization for disclosure.
Patient, parent, guardian

Clear
Authorized Agent - Power of attorney attached

Clear
File Upload

Cancelof
Witness

Clear
Date

MonthDayYear
Date

Authorization for Release of Mental Health, Alcohol & Drug Abuse, and Other Personal Health Information

Notice to Patient and Receiving Agency:

Revocation of Authorization

VALID MENTAL HEALTH RELEASE CHECKLIST