1. I authorize the use or disclosure of the above patient’s health information as follows:First Name(Required)MILastMaidenSocial SecurityDate of Birth(Required) DD slash MM slash YYYY 2. The following individual or organization is authorized to receive and disclose information: Primary Contact/RelationshipOrganization NameAddress:(Required) Address Apt City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone:(Required)Alternate Phone NumberFaxAlternate Fax NumberEmail(Required) 3. Provide a specific and meaningful description of the information, including dates where appropriate: Discharge Summary Yes No BioPsych/Social Assessment Yes No Progress and/or Progress Notes Yes No Mental Health Evaluation Yes No Master Treatment Plan Yes No Correspondence/letter Yes No Other (Please be specific)Dates of Treatment Requesting DD slash MM slash YYYY 4. For the purpose of Continuity of Care or:5. I understand that I have a right to revoke this authorization at any time. To revoke this authorization, I must submit a written request to the Administrative Office Department. I understand that the revocation will not apply to information that has already been released in response to this authorization:6. This authorization will expire on the following date or event7. Generally, Boyd Andrew Community Services will not condition treatment on the provision of this authorization, unless services are solely for the purpose of creating information for disclosure to a third party:8. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure, and the information may no longer be protected by federal confidentiality rules:9. By initialing here I would like a copy of this authorization.Signature of Patient:(Required)Date:(Required) DD slash MM slash YYYY Witness Signature:Date: DD slash MM slash YYYY Signature of Parent/Personal Representative:Date: DD slash MM slash YYYY If the Patient is a minor (under age 18), both the Patient and Personal Representative must sign. Nature of the Personal Representative’s authority to act for the Patient Parent Legal Guardian Court-appointed Guardian Other Signature of Parent/Personal Representative:
