Consent for Release of Confidential Information Form

CONSENT FOR RELEASE OF INFORMATION

Please complete the following form in its entirety to authorize MIND 24-7 to send and/or receive confidential medical information. Please note that medical records are processed Monday - Friday, 8:00 AM - 4:30 PM. Please allow up to 5 business days to process this request.
Patient Name*
Patient Date of Birth*

MonthDayYear
Date
I authorize MIND 24-7 to*

SENDRECEIVE
The following information:*

Confirmation of presence in treatmentMedical history and evaluation(s)Psychiatric History and AssessmentPsychological AssessmentBiopsychosocial AssessmentLaboratory Test ResultsProgress in treatmentTreatment plansDischarge Summary and RecommendationsOther
Through the following methods*

ElectronicOralWritten
To the following Person or Agency*
Phone number
Fax number
Email
example@example.com
Relationship to Patient*
The above information will be used for the following purposes*

Continuity of treatment – Patient History – Case Management ServicesEmergency Contact – General UpdatesCourt Services / Legal Purposes / Probation / Disability Claiming / Unemployment Claiming / Employment ContinuityOther
My records are protected under Federal Confidentiality regulations (42 CFR Part 2) published August 10, 1987, and the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191), 42 U.S.C. Section 1320d, et. Seq and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I understand that my medical record may contain information concerning my psychiatric, psychological, drug or alcohol abuse, HIV/Acquired Immune Deficiency Syndrome (AIDS), and/or related conditions.*

I UNDERSTAND
I may revoke this authorization at any time upon written notice to MIND 24-7. I acknowledge that such revocation will not be effective if Mind 24-7 has already acted in reliance upon this authorization.*

I UNDERSTAND
I may revoke this authorization at any time upon written notice to MIND 24-7. I acknowledge that such revocation will not be effective if MIND 24-7 has already acted in reliance upon this authorization.*

I UNDERSTAND
This authorization is valid (if not previously revoked) this consent will terminate upon 90 days from the date of signature of this form, or the following event/condition: (PLEASE EXPLAIN IN OTHER BELOW), or the completion of treatment, or at the time of the final insurance billing, as the case may be, whichever is later.*

I UNDERSTAND
PROHIBITION ON RE-DISCLOSURE: This information has been disclosed from records protected by Federal Confidentiality Rules 42 CFR part 2 The Federal rules prohibit making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse client.*

I UNDERSTAND
Signature
Type a question*

Clear
Name*
PROOF OF IDENTIFICATION*

Please also include PROOF OF IDENTIFICATION such as a picture of your driver’s license, proof of agency employment, a copy of a Power of Attorney, or other forms of Guardianship papers.
Cancelof
Should be Empty:

Signature