Authorization For Use and Disclosure of Protected Health Information

Authorization For Use and Disclosure of Protected Health Information
Client Information
Name *

First Name Middle Name Last Name
Date of Birth *

Month Day Year
I authorize Northwestern Mental Health Center to do the following: *

Obtain From (One-Way: NWMHC gets records) Release To (One-Way: NWMHC sends records) Exchange With (Two-Way: NWMHC gets and sends records)
Who has the information you want released?
Name/Organization *
Attention

Phone *
Fax
Where do you want the information to be sent?
Name/Organization *
Attention

Phone *
Fax
What are the approximate dates of information you want released? *
Purpose of Release *

Coordination of Care Insurance application Workers Compensation Insurance payment/claim School Litigation/Legal Personal Use
What do you want released? *

Billing Records Chemical Dependency/ Substance Abuse Reports Comprehensive Assessment (SUD) Consultations Comprehensive Evaluation/ Diagnostic Assessment Discharge Summary Educational Information Crisis Documentation/ Emergency Reports History and Physical Exams Medical/Laboratory Records Medication List Progress/Provider Notes Psychiatric Reports Psychological Testing Treatment/Service Plan
All information regarding alcohol and/or drug abuse or behavioral health will be released unless you restrict by initialing:

Do not release alcohol and/or drug abuse information Do not release behavioral health information
Initials *
Release Method / Format requested: *

Mail Fax Pick up (Photo ID is required at pickup time)
When is it needed? *

Month Day Year
NWMHC processes requests as they are received, but law allows us a maximum of 30 days to complete request.
- I understand that this authorization lasts for one year after the date of signature unless specified otherwise.
- I understand that I may revoke this authorization at any time by notifying the providing organization in writing, and it will be effective on the date notified except to the extent action has already been taken in reliance on it.
- I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer be protected by Federal privacy regulations.
- I understand this consent for release of alcohol and/or drug abuse information is subject to revocation at any time except to the extent that the program or person which is to make the disclosure has already acted in reliance on it.
- I understand that Northwestern Mental Health Center may not condition my treatment, payment, enrollment, or eligibility for benefits on my signing this authorization.
- I understand, upon request, I will receive a copy of this form after I have signed it.
- I understand that in compliance with MN Statute 144.293, WI Administrative Code HHS117, NDCC 23-12-14, Federal Rule 45 CFR 164.524; Charges may apply in ID. I may be required to pay a fee for retrieval and photocopying of records and/or supervising inspection of medical records.
- I understand a photocopy or fax of this form is the same as the original.
I wish for this authorization to expire prior to one year after the date of signature.
Date of Authorization Expiration

Month Day Year
ATTENTION: This is a legal document. Please read carefully.
By signing, you agree that you understand and accept the terms in this form.
- If the client is 18 years of age or older, the client must sign and date the form.
- If the client is 18 years of age or older and is incapable of signing, a legally authorized substitute may sign and date the form.
- If the client is 17 years of age or younger, the client’s parent or legal guardian must sign and date the form, unless an exception exists under state or federal law.
Please select one: *

I am 18 years of age or older and will be signing this form Client is 18 years of age of older and is incapable of signing Client is 17 years of age or younger I am 17 years of age or younger, but can sign due to a legal exception
Client Name *

First Name Last Name
Legal Exception *
Name of Authorized Signee *

First Name Last Name
Relationship *
Relationship *
Authorized signature and date are required to release records. My signature
indicates that I am legally authorized to sign.
Signature *

Clear
Date *

Month Day Year
Should be Empty:

Street Address
Street Address Line 2
City	State
Zip Code	Country

Street Address
Street Address Line 2
City	State
Zip Code	Country