Authorization for Use or Disclosure of Protected Health Information

Authorization for Use or Disclosure of Protected Health Information

(Release of Information)
Client Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
ClientPhone Number *

Area Code Phone Number
Client Email Address
I hereby request and authorize:

Indy Behavioral Health

2611 Waterfront Parkway East Drive, Suite 370

Indianapolis, IN 46214

Phone: 317.978.0257 Fax: 317.974.9077
to *

Receive Disclose
a copy of my mental health information to/from the person or agency listed below:
Name or Facility Name *
Typically a Therapist, Hospital, or Primary Care Provider
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Date of Authorization

Month Day Year
Date Hour Minutes AM/PM Option
This consent is subject to revocation at any time except to the extent that the individual/agency which is to make the disclosure has already taken action in reliance on it. If not previously revoked, this consent will terminate in 12 months or upon termination of treatment.
Information to be released:(Note: Requests for release of psychotherapy notes cannot be combined with any other type of request.)

Entire record, including those regarding drug, alcohol, or mental health treatment to the person(s) listed above. Authorization for Psychotherapy Notes ONLY (Important: If this authorization is for Psychotherapy Notes, you must not use it as an authorization for any other type of protected health information.)
Purpose of Information Release

Further Mental/Other healthcare Payment of Insurance Claim Legal Investigation Applying for Insurance Determination Disability At the Request of the Individual
Authorization and Signature: I authorize the release of my confidential protected health information, as described in my directions above.

Clear
DateTime
If signed by a personal representative, Your name:
Type your name
Indicate your relationship to the client and/or reason and legal authority for signing:
Patient is:

Minor Incompetent Disabled Deceased
Legal Authority:

Parent Legal Guardian Representative of Deceased
** This information has been disclosed from records protected by federal confidentiality rules (42 CFR part 2). The federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.
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