AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION

AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION
Patient Name:*
Date of Birth:*

MonthDayYear
Address:*

Street Address

Street Address Line 2

City, State, Zip CodeState

Zip Code
SSN (Last 4 #):*
Telephone #:*
I hereby voluntarily authorize the use and disclosure of protected health information (PHI) from my records from:

Facility Authorized to Receive Information:

Wilmington Mental Health, PLLC (WMH)
3825 Market St, Ste 4
Wilmington, NC 28403
Telephone: 910-777-5575 / Fax: 910-777-5273

Facility or Individual(s) Authorized to Release Information:
Name:*
Address: *

Street Address

Street Address Line 2

CityState / Province

City/State/Zip
Telephone: *
Fax:
This consent will expire automatically one year from the date on which it is signed unless a date for treatment records to be released is specified next:
From (date)

MonthDayYear
Date
To (date)

MonthDayYear
Date
Health Information that may be used / disclosed is limited to the following: [check appropriate box(es)]*

Patient Information/Social HistoryIntake Summary/Diagnostic Assessment*Treatment Plan/Attendance RecordsMedical History/Physical ExamMedication RecordsDischarge SummaryLaboratory ReportsAlcohol or Drug Evaluation***Psychological Testing or EvaluationPsychiatric EvaluationMedication RecordsEntire Record**
* Comprehensive Clinical Assessments include background history, legal history, previous diagnostic test results, medication list, allergies, operative notes, consults, and psychiatric/behavioral diagnosis. ** Mental Health Records do not include psychotherapy notes. *** Federal rules restrict any use of the information to criminally investigate or prosecute alcohol or drug abuse patients. The circumstances under which disclosure is permitted or required by state or federal confidentiality rules are described in our Notice of Privacy Practices.
PURPOSE OF RELEASE (check reason):*

Continuity of carePersonal useDisabilityEmployerLegal PurposeSchoolService coordinationOther
PATIENT’S RIGHTS: I understand that:
- State and Federal privacy laws protect my records. WMH will not share or use my health information without my permission other than by ways listed in WMH’s Notice of Privacy Practices or as required by law. The Notice of Privacy Practices is available at wilmingtonmentalhealth.com. A fee may be charged for providing the protected health information.
- I have the right to revoke this authorization at any time unless Wilmington Mental Health has acted in reliance upon it. Such revocation must be in writing and received by Wilmington Mental Health to be effective. Refusing to sign this form will not prevent my ability to get treatment, payment, or eligibility of care.
- Once my health information is released, the recipient may disclose or share my information with others and my information may no longer be protected by federal and state privacy protections.
- This request/authorization to release records and information has been explained to me and I fully understand it, including the nature of the records, their contents, and consequences and implications of their release. The release of information is limited to the minimum necessary to accomplish the purpose for which the request is made. This authorization is being completed freely, voluntarily and without coercion.
- I hereby discharge the releasing facility, its agents and employees from any and all liabilities, responsibilities, damages, and claims which might arise from the release of information authorized herein, including sensitive information as indicated above.
EXPIRATION OF AUTHORIZATION
This authorization will end one year from the date it is signed unless another date is specified here:
Patient Signature:*

Clear
Date:*

MonthDayYear
OR
Legal Representative***

Clear
Date:

MonthDayYear
*** If patient lacks legal capacity or is unable to sign, an authorized personal representative may sign this form - written proof may be required.

NOTE - This information is to be treated in accordance with (HIPAA) privacy regulations This information has been disclosed to you from records the confidentiality of which may protected by federal and/or state law (45 CFR Part 164 and 164; 42 CFR Part 2). You are prohibited from making 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 G.S. 122C-53 through G.S. 122C-56. A general authorization for the release of other medical information is NOT sufficient for this purpose.
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