Guidelines for Completing the CMMHC Authorization for Disclosure
Central Minnesota Mental Health Center (CMMHC) recognizes the importance of client confidentiality, as well as, the importance of coordinating care and treatment with other professionals, family, friends and others involved in your care. Please review all itemson this form and contact CMMHC with any questions concerning this form at the offices listed below or on our website: https://cmmhc.org
Client Information: Complete this entire section with clear and legible writing so the information identifies the client whose information is being requested/released.
I Authorize: Please check by either: 1) Release To, 2) Receive From, or 3) Both Release & Receive. If you choose only "Release To" your CMMHC provider can only share information; If you choose only to "Receive From" your CMMHC provider CANNOT share any information;choose "Both Release & Receive" your CMMHC provider may share and receive information from the agency/ name you listed on the form. CMMHC has centralized records. Please identify which CMMHC location correspondence should be sent to. If you specify a contact name/department, that will help us ensure the information gets routed to the correct person.
With Agency/ Name: Indicate clearly and legibly where or whom you wish to send/ receive information with. Be as specific as possible.
What do you want Released? The purpose of this section is to have us share the information you want us to. Only the specific information checked will be released. If no dates are specified, we will only release the most recent DA and 3 progress notes. Minimum Necessary means we will use the least amoutn of information possible to accomplish the desired task. Select "Verbal" if you want us to release or obtain information verbally with the listed releasing/obtaining party. Verbal is all inclusive. "Screening Tools" will include: SDQ/CBCL, CASII/ECSII, and Locus.
Purpose of the Release: Identify the reason you need to release/ request information. This helps CMMHC appropriately provide care and track releasing of confidential information. It informs us who may be responsible for the cost of medical records being released and is required on each release. *Fees may be charged in accordance with MN statutes 144.292 and Federal Rule 45 CFR 164.524 (where applicable).
Substance Use Disorder (SUD) Special Consent: This section must be completed to allow CMMHC to release SUD records on your behalf. This information is 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 the written consent of the person 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. The dates of special consents are required to release SUD records. Select "Verbal" if you want us to release or obtain SUD information verbally with the listed releasing/obtaining party. Verbal is all inclusive.
Preferred Method: This tells us how you would like your information provided. We can print and mail the documents, send them by fax, CONFIDENTIAL email, or we can print the records and make them available for you to pick-up at one of our locations.
Authorization and Revocation: Signing this form (or having the parent/ legal guardian sign for the client) will grant authorization to share/ receive confidential information. Please sign and date this form to validate this authorization. If signed by someone other than the the client or parent of a minor, you will be required to provide written profo of your authority (legal paperwork). This authorization will automatically expire in neoyearfr m o thedate s igedn uless a differentdate orev etn has been identified, not to exceed 5 years per (144.293, Subd. 4) from the date signed. This authorization can be revoked at any time by your written request to our HIM Department within our organization.
Helpful Tips:
You may only enter one entity, clinic, or individual per Release of Authorization of Disclosure. If requesting records, please allow 7-10 business days for processing of the Release of Information (ROI). In some cases, it can take up to 30 days (45 CFR 164.524(b)(2)(b)(i). For questions or concerns reading this form, please contact the Health Information Management (HIM) Department: by phone at:320.202.2028, by fax at: 320.202.2005, or by email at: HIMDept@cmmhc.com