Authorization To Release Information (Page 2 of 2) in pdf

By initialing below, I agree to disclose the following types of records:

_______ Mental health treatment provider or program

_______ Substance/alcohol/drug Abuse treatment provider or program

_______ HIV infection status or test results: Maine law requires us to tell you that releasing this information may have

implications. Positive implications may include giving you more complete care, and negative implications may include

discrimination if the data is misused. DHHS will protect your HIV data, and all your records, as the law requires.

I (individual/personal representative of individual) permit DHHS to release and/or obtain my records as written on Page 1

of this form. I understand and agree to the following:

•

This form will expire one year from the date I sign below, unless I revoke (take back) my permission sooner by

completing, signing and sending in the Revocation Form found on the DHHS website at

I may call DHHS at 207-287-3707 and ask for the office where

I receive services if I need help revoking this form.

•

I understand that taking back my permission to release my information does not apply to the information that

was already shared after I signed this form.

•

If I take back my permission to release my information, or if I refuse to release some or all of my healthcare or

insurance information, that may result in improper diagnosis or treatment, denial of insurance coverage or a

claim for health benefits, or other adverse consequences.

•

This form permits the people or offices listed on Page 1 to speak to each other for the purpose(s) on this form.

•

If I am disclosing healthcare information, I agree that records of other providers (such as doctors, hospitals, and

counselors) in my file are included in this release.

•

Unless I am applying for benefits, DHHS will not condition my treatment, payment for services, or benefits

on whether I sign this form.

•

I have the right to make a written request to review my records. If I wish to receive a copy of my healthcare

or billing information, a fee may be charged as permitted by law.

•

If I want to review my mental health program or provider records before they are released, I must check

THIS BOX.  I understand that the review will be supervised.

•

DHHS offices will keep my information confidential as required by law. If I give my permission to share my

records with people who are not required by law to keep them private, they may no longer be protected by

federal confidentiality laws.

•

If alcohol or drug treatment or program records are included in this release, federal law requires the person

sharing those records to include a notice saying that such information may not be re-released or shared

without my written permission, unless required or permitted by law.

•

I am signing this form voluntarily, and I have the right to a signed copy of this form if I request one.

Date: ____________

Signature_____________________________________________________________________

Personal Representative’s authority to sign: _____________________________________________________________

DHHS Authorization Form 3/16

Page 2 of 2

Authorization To Release Information Page 2

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