• Authorization For Use and Disclosure of Protected Health Information

  • Client Information

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  • Who has the information you want released?

  • Where do you want the information to be sent?



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    • 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.
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  • 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.
  • Authorized signature and date are required to release records. My signature
    indicates that I am legally authorized to sign.

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