Release of Information

Release of Information

For Mental Health and Substance Use Disorder Records

Revised 1/26
Client Name:*
Date of Birth:*

MonthDayYear
Date
1. Purpose / Type of Request
Treatment, Care Coordination, or Planning - share records with providers, payors, or care team.Records Request / Personal Copy - obtain/disclose records for client, legal, or administrative useOther
Dates of Records to Be Disclosed From:*

MonthDayYear
Date
To:*

MonthDayYear
Date

2. Information to Be Disclosed / Obtained*

Rows	Assessment	Treatment Plan
Psychiatric
Mental Health
Vocational
Substance Use / SUD

Information to Be Disclosed / Obtained Continued

Rows	Medication Records	Progress Notes
Psychiatric
Substance Use / SUD

Information to Be Disclosed / Obtained Continued

Rows	Admission Summary	Discharge Summary	Progress Notes	Legal
Mental Health

Information to Be Disclosed / Obtained Continued

Rows Progress Notes

Vocational
Other/Please Specify:
HIV/AIDS information

Rows	Progress Notes
Vocational

3. 42 CFR Part 2 - Program Records & TPO Authorization
I understand and authorize that my SUD treatment records, including program records, assessments, group or individual counseling notes, and administrative records, may be disclosed to staff, providers, payors, or other entities involved in Treatment, Payment, or Healthcare Operations (TPO) as permitted under 42 CFR Part 2.

I understand that:
- This dislocosure may include records otherwise protected under Part 2.
- Redisclosure by recipients is strictly prohibited unless authorized in writing.
- I may revoke this authorization at any time in writing, except for disclosures already made in reliance on this authorization.
- Signing this authorization is voluntary and will not affect my treatment or benefits.
4. Parties Authorized to Obtain/Disclose Information
Agency / Facility / Person:*
Address & Phone:*
Right to Inspect/Copy: Recipient may inspect or copy information disclosed under HIPAA.

Redisclosure Restrictions:
- HIPAA information may be subject to redisclosure if recipient is not HIPAA-covered.
- Part 2 SUD information may not be redisclosed without written consent.
- IMHDDCA: Mental Health records may only be redisclosed as authorized in this form; prohibited for third-party payers except as required for payment or care coordination.
5. Special Protections / Legal Requirements
IMHDDCA - Mental Health Records
- Third-party payer disclosure is limited to information necessary for payment or administrative purposes.
- Redisclosure to other entities requires express authorization.
- Minor clients (12–17): parent consent is optional except for payment or legal responsibility; client consent controls access to MH treatment records.
42 CFR Part 2 - SUD Records
- SUD information cannot be disclosed without consent except as allowed under TPO or court order.
- Redisclosure is prohibited unless specifically authorized.
- Prohibited from use in legal proceedings against the client unless expressly authorized.
- Can limit redisclosure by category/class of recipient.
- New patient rights (2024 rule) are incorporated: notice of confidentiality, right to revoke, and scope limitations.
6. Format of Disclosure
WrittenVerbalElectronic
www.kennethyoung.org
847.524.8800

Kenneth Young Center
7. Expiration and Revocation
This authorization will expire:*

MonthDayYear
- Not to exceed 12 months from the date signed or at the end of treatment, whichever comes first.
- Authorization must specify a calendar date expiration, or the requested information will only be disclosed on the day the form is received.
- I may revoke this authorization at any time by submitting a written request to KYC or the SUD Program.
- Revocation does not apply to information already used or disclosed in reliance on this authorization.
8. Client Understanding and Consequences
- If I refuse to sign, the requested information will not be disclosed or obtained.
- Refusal may limit SUD treatment or TPO coordination.
- I have the right to ask questions about this form before signing.
9. How to File a Complaint
- KYC Privacy Official (847) 524-8800
- U.S. HHS/OCR: 1-800-368-1019 | www.hhs.gov/ocr
- Guardianship & Advocacy Commission: (866) 274-8023
- Equip for Equality: (800) 537-2632
- Illinois DHS DBHR: 1-800-843-6154 | DHS.DBHR.SUDHelp@Illinois.gov
- The Joint Commission: (630) 792-5000 | www.jointcommission.org
10. Acknowledgment and Signatures
By signing this document, I acknowledge that I understand the purpose and scope of this release, the protections under 42 CFR Part 2 and IMHDDCA, and that I have had the opportunity to ask questions about this authorization.
Client (Required for Minors 12-17, in addition to parent/guardian)

First NameLast Name
Client Signature (Required for Minors 12-17 in addition to parent/guardian)
Date

MonthDayYear
Date
Parent, Authorized Representative, Legal Guardian (If Applicable)

First NameLast Name
Parent, Authorized Representative, Legal Guardian Signature (If Applicable)
Date

MonthDayYear
Date
Authorized Representative or Legal Guardian must provide copy of court order granting authority.
Date*

MonthDayYear
Date
www.kennethyoung.org
847.524.8800
Should be Empty:

1. Purpose / Type of Request

3. 42 CFR Part 2 - Program Records & TPO Authorization

4. Parties Authorized to Obtain/Disclose Information

5. Special Protections / Legal Requirements

6. Format of Disclosure

Kenneth Young Center

7. Expiration and Revocation

8. Client Understanding and Consequences

9. How to File a Complaint

10. Acknowledgment and Signatures