On-line Authorization for Release

This authorization may not be used for medical health information Correctional Healthcare Companies will not condition treatment on this authorization. Mental health information disclosed pursuant to this authorization may not be further disclosed except pursuant to authorization from the patient or patient's representative. If this authorization is for psychotherapy notes, it must not be used as an authorization for any other type or protected health information.

I hereby authorize to release*
(enter name of facility)
Section A: Mental Health information (as described below). State specific Mental Health information to be disclosed including date(s) or date range:*
Section B: Substance Abuse Treatment information (as indicated below): If Substance Abuse Treatment records are being authorized, check all relevant below:*
Include date(s) or date range*
At request of Patient and/or*
(state the purpose of disclosure)
From the records of*
(enter ID # DOB and Patient's Name)
To:*
- Self
- Authorized Attorney
- Health Care Facility
- Other
Name*
Phone*
Fax*
Address*
Street Address Address Line 2 City State ZIP Code
I hereby release and hold harmless Correctional Healthcare Companies and its employees from any liability which may occur as a result of the disclosure or dissemination of the records or information contained therein resulting from the access permitted to the authorized attorney, health care facility, other as specified or self. I understand that I have the right to revoke this authorization at any time prior to disclosure by giving written notice (witnessed by someone who knows my identity) to the Facility Privacy Officer. I understand I have the right to inspect and receive a copy of the material disclosed.*
- Yes
- No
The identified health information may be provided verbally or over the phone to the person or entity identified above.
Expiration*
- 45 days from the date of signature
- Upon the occurrence of the following event (must relate to the individual or purpose of the athorization)
This authorization will expire (check one)
Signature*
First Last Relationship
Signature of Patient or Person Authorized to Consent - I certify under perjury in the second degree, that the above facts are true and correct to the best of my knowledge.
Date*
Date Format: MM slash DD slash YYYY

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