CARELON PROVIDER CONSENT FORM

PARTICIPANT NAME
(Participant DATE OF BIRTH)

MonthDayYear
Date
Phone Number to release/disclose to Carelon Behavioral Health
Format: (000) 000-0000.
Client Address to release/disclose to Carelon Behavioral Health
Verbal/ Telephone #U.S. Mail/In-personFax
Verbal/ Telephone #
Format: (000) 000-0000.
Fax
I CONSENT TO THE RELEASE OF THE SPECIFIC INFORMATION CHECKED OFF BELOW:
Discharge summaryPsychological testing resultsPsychiatric EvaluationProgress NotesLaboratory dataComplete Medical RecordHistory and PhysicalTreatment PlanAlcohol and Drug Abuse InformationHistory of Mental Health TreatmentHIV/AIDS InformationOther (Specify
Other explain
For date(s) of service: From/to

MonthDayYear
Date
Coordination of Care Case Management Patient Care Quality of Care Review
Other
THIS INFORMATION IS NEEDED FOR THE FOLLOWING PURPOSE(S):
However, my withdrawal/revocation will not affect the rights of anyone acting in reliance on this consent prior to

noticoftwithdrawal/revocation. e he Unless otherwise revoked, this consent will expire on the following date, event, or condition, this consent will remain valid for not more than twelve (12) months from the date this consent was signed.

Carelon Behavioral Health will not condition payment, treatment, enrollment or eligibility for benefits on whether I sign this authorization. I am aware that the information disclosed as part of this authorization and contained in my record may be given to another agency/person if requested.

Carelon Behavioral Health will not condition payment, treatment, enrollment or eligibility for benefits on whether I sign this authorization. I understand that by not signing this form, the services provided to me by Carelon Behavioral Health may be limited if benefits cannot be determined. I am aware that the information disclosed as part of this authorization may be re-disclosed and no longer protected under federal or state law.
I understand that my records are protected under state and federal law and cannot be disclosed without my written consent except as otherwise specifically provided by law. Further, I understand that if my records involve alcohol or drug abuse, they are also protected under Federal Regulation 42 CFR Part 2, Confidentiality of Alcohol and Drug Abuse Patient Records. I also understand that disclosure of HIV/AIDS related information may only be: (1) limited to specific circumstances: and/or (2) restricted by me.

I have read carefully and understand the above statements and expressly and voluntarily consent to disclosure of my confidential health care information (including alcohol and drug abuse records of my condition and HIV/AIDS information, if checked above) to those persons/agencies named above.

I understand that I may withdraw and revoke this consent at any time by notifying Carelon Behavioral Health, either orally or in writing, at the following address:
.
Signature of participant legal guardian or parent

Clear
Signature of participant legal guardian or parent
Date

MonthDayYear
Date
Date

MonthDayYear
Date
Relationship if not participant or if participant is under 18

Clear
Date

MonthDayYear
Date
Signature of participant, if under 18
Date

MonthDayYear
Date
Should be Empty:

I CONSENT TO THE RELEASE OF THE SPECIFIC INFORMATION CHECKED OFF BELOW:

THIS INFORMATION IS NEEDED FOR THE FOLLOWING PURPOSE(S):