Authorization To Release Information
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2Authorization to Release Information
We are committed to the privacy of your health information. Please read this form carefully.
Office of MaineCare Services
Substance Abuse and Mental Health Services
Office for Family Independence including Medical Review Team
Office of Child and Family Services
Maine Centers for Disease Control and Prevention
Office of Aging and Disability Services
Dorothea Dix Psychiatric Center
Office of Administrative Hearings
Riverview Psychiatric Center
Other:
Individual’s Name:
Individual’s Date of Birth:
Individual’s Social Security Number:
Individual’s Address:
Street
Town/City
State
Zip Code
Records to be released, including written, electronic and verbal communication:
All Healthcare, including treatment, services, supplies and medicines
B
Claims Information
illing, payment, income, banking, tax, asset, and/or other information regarding
eligibility for DHHS program benefits such as MaineCare
Other:
_________________________________________________________________________________________________
Limit to the following date(s) or type(s) of information:
(e.g. “lab test dated June 2, 2013” or “hospital records from 1/1/14 - 1/15/14”)
I authorize the DHHS office(s) checked above to:
Release my information to:
Obtain my information from:
Name: ___________________________________________________________________________________________
Address: __________________________________________________________________________________________
Street
Town/City
State
Zip Code
Fax No., where applicable: _______________________ Phone No. to verify Receipt of Fax _______________________
If requesting that electronic information be transmitted by email, please clearly print the email address below:
I understand that DHHS systems may not be able to send my information securely through email. I understand that
email and the internet have risks that DHHS cannot control and that the information possibly could be read by a third
party. I accept those risks and still request that DHHS send my information by email. Initials _______
Please allow the office(s) named above to disclose my information for the following purpose(s):
For a legal matter, including an administrative hearing To see if I qualify for insurance coverage or benefits
For coordination of my care A Personal Request Other (note here):
DHHS Authorization Form 3/16
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