AUTHORIZATION TO USE AND DISCLOSE HEALTH INFORMATION

AUTHORIZATION TO USE AND DISCLOSE HEALTH INFORMATION

Sentinel Mental Health INC
I, First Last [Insert Name of Patient/Client], whose Date of birth is Date* Authorize Sentinel Mental Health INC to disclose to and/or obtain from:
A Last Name The following information:
[insert name of Person or Title of Person or Organization]

Description of Information to be Disclosed
(Patient/Client please check each box to be disclosed)
AssessmentPsychosocial EvaluationPsychological EvaluationPsychiatric EvaluationTreatment Plan or SummaryCurrent Treatment UpdateMedication Management InformationPresence/Participation in TreatmentNursing/Medical InformationEducational InformationDischarge/Transfer SummaryContinuing Care PlanProgress in TreatmentDemographic InformationOther
Purpose

The purpose of this disclosure of information is to improve assessment and treatment planning, share information relevant to treatment and when appropriate, coordinate treatment services.

If the purpose is other than marketing, scale of information, research or as specified above, please specify,
Expiration
Unless sooner revoked, this authorization expires on the following date: Date or as otherwise indicated. One hundred and eighty (180) days from the date this Authorization is signed
Conditions

I further understand that Sentinel Mental Health INC will not condition my treatment on whether I give authorization for the requested disclosure. However, it has been explained to me that failure to sign this authorization may have affect my ability to obtain treatment.

Form of Disclosure

Unless you have specifically requested in writing that the disclosure be made in a certain format, we reserve the right to disclose information as permitted by this authorization in any manner that we deem to be appropriate and consistent with applicable law, including, but not limited to, verbally, in paper format or electronically.

Redisclosure

Federal law prohibits the person or organization to whom disclosure is made from making any further disclosure of substance abuse treatment information unless further disclosure is expressly permitted by the written authorization of the person to whom it pertains or as otherwise permitted by 42 C.F.R. Part 2. I will be given a copy of this authorization for my record.
Signature

Clear
Signiture of Patient/Client
Date

MonthDayYear
Date
Signature

Clear
Signature of Parent, Guardian or Personal Representative
Date

MonthDayYear
Date
Should be Empty: