AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION45 C.F.R, Parts 160 and 164; 42 C.F.R. Part 2; G.S. 122C
This authorization form implements the requirements for client authorization to use and disclose health information protected by the federal health privacy law (45 C.F.R. Parts 160, 164), the federal drug and alcohol confidentiality law (42 C.F.R. Part 2), and the state confidentiality law governing mental health, developmental disabilities, and substance abuse services (G.S. 122 C).
CLIENT’S NAME: RECORD NUMBER:
DATE OF BIRTH: SOCIAL SECURITY #
I, , authorize __PEACE OF MIND, INC _______________________ Name of client or client’s legally responsible person Agency or person authorized to use and disclose the information
to use or disclose to/with __________________________________________________ Name of agency or person to whom the requested use or disclosure will be made (include address, if applicable)
THIS DATA SHALL INCLUDE (Initial beside data to be used or disclosed) ____Assessments ____Progress Notes ____Substance Abuse/Treatment ____Psychiatric Evaluations ____Service Plans/Goals ____HIV/AIDS Information ____Psychological Evaluations ____Discharge Summary ____Social, Developmental, Medical History ____Diagnoses ____Financial/Reimbursement ____Other:
PURPOSE OF USE OR DISCLOSURE (Initial beside reason for disclosure) ____At the request of the individual ____Assessment/Evaluation ____Coordination of Care ____Court Proceedings ____Determination of Benefits ____ Other __________________________
Information requested should be mailed to this address:
REDISCLOSUREOnce information is disclosed pursuant to this signed authorization, I understand that the federal privacy law (45 C.F.R. Parts 160 & 164) protecting health information may not apply to the recipient of the information and, therefore, may not prohibit the recipient from redisclosing it. Other laws, however, may prohibit redisclosure. When we disclose mental health and developmental disabilities information protected by state law (G.S. 122C) or substance abuse treatment information protected by federal law (42 C.F.R. Part 2), we must inform the recipient of the information that disclosure is prohibited except as permitted or required by these two laws. Our Notice of Privacy Practices describes the circumstances where disclosure is permitted or required by these laws.
REVOCATION AND EXPIRATION I understand that, with certain exceptions, I have the right to revoke this authorization at any time. The procedure for how I may revoke this authorization, as well as the exceptions to my right to revoke, are explained in the agency’s Notice of Privacy Practices, a copy of which has been given to me.
If not revoked earlier, this consent shall be valid for one year from the date signed unless otherwise indicated below:
Date of expiration, if less than one year Event, if less than one year
NOTICE OF VOLUNTARINESS I understand that I may refuse to sign this authorization form. I understand that ________________ will not deny or refuse to provide treatment, payment, enrollment in a health plan, or eligibility for benefits if I refuse to sign.
Signature of Client Date Witness (required if symbol or mark is used by client or LRP)
Signature of legally responsible person, if required Date
Please explain LRP authority to act on behalf of the client:
Power of Attorney Guardian Staff Signature Other: _________________________________________
____________________________________________________________________________________________________________ AUTHORIZATION FOR USE & DISCLOSURE |
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____Assessments |
____Progress Notes |
____Substance Abuse/Treatment |
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____Psychiatric Evaluations |
____Service Plans/Goals |
____HIV/AIDS Information |
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____Psychological Evaluations |
____Discharge Summary |
____Social, Developmental, Medical History |
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____Diagnoses |
____Financial/Reimbursement |
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____Other: |
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____At the request of the individual |
____Assessment/Evaluation |
____Coordination of Care |
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____Court Proceedings |
____Determination of Benefits |
____ Other ___________________________________________________ |
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Information requested should be mailed to this address: |
____________________________________________________________ |
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____________________________________________________________ |
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Peace of Mind, Inc. |
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817 West Front Street P.O. Box 2088 Lillington, NC 27546-2088 Phone: (910) 814 - 2197 Fax: (910) 814 - 2167 |
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