Authorization to Release Protected Confidential Information

Authorization to Release Protected Confidential Information

Complete this authorization form and provide the required dates, release details, contact information, and acknowledgements.
Patient Information
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Authorization Dates
Effective Date

MonthDayYear
This release of authorization is active from this date.
Expiration Date

MonthDayYear
This date is the date that this release will expire. If you do not change it the default is 12 months. You need to change the date if you want it something other than 12 months.
Authorized Organization or Person
Organization/Person/Provider/Insurance
Name
Release Mechanism -- Please identify how you would like these records released. Whichever method you choose will be the method that we use to release the records.
PORTAL IS ONLY AN OPTION IF YOU ARE HAVING RECORDS RELEASED TO YOURSELF. PLEASE CHANGE THAT OPTION OR NO RECORDS WILL BE RELEASED.
Fax #
E-mail
example@example.com
Record Types to be released (SELECT ALL THAT APPLY) Only records specifically checked will be released. I authorize Serenity Mental health to release/obtain the following records:
Mental health Records Only records checked will be released. I authorize Serenity to release/obtain the following mental health records:

Other
Substance Use Disorder Records Only records checked will be released. I authorize Serenity to release/obtain the following substance use disorder records:

Other
Med Management Records Only records checked will be released. I authorize Serenity to release/obtain the following Med Management records:

Other
Crisis Intervention Records Only records checked will be released. I authorize Serenity to release/obtain the following crisis intervention records:

Other
Preventative Care Records Only records checked will be released. I authorize Serenity to release/obtain the following Preventative Care records:

Other
Targeted Case Management Records Only records checked will be released. I authorize Serenity to release/obtain the following Targeted Case Management records:

Other
Rehabilitation Services & Support Services (BST/PSR/PRSS) Records Only records checked will be released. I authorize Serenity to release/obtain the following Rehabilitation Services & Support Services (BST/PSR/PRSS) records:

Other
Disclosing for the purpose of:
Please enter the purpose of your disclosure; should be as specific as possible.
Acknowledgements
Email Release Acknowledgement
Fax Release Acknowledgement
Mental Health Disclosure:
Substance Use Disorder Disclosure
Signature
Date of Signature

MonthDayYear
Date
Should be Empty:

Authorization to Release Protected Confidential Information

Patient Information

Authorization Dates

Authorized Organization or Person

Acknowledgements