Consent For Release Of Confidential Information
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1
2,
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FOUR COUNTY MENTAL HEALTH CENTER
INC
CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION
.
/
.
.
3751 W
MAIN
P
O
BOX 688
,
INDEPENDENCE
KS 67301
:
:
PATIENT NAME
CASE NUMBER
:
/
/
:
4
DATE OF BIRTH
LAST
DIGITS OF SOCIAL SECURITY NUMBER
/
:
I HEREBY AUTHORIZE FOUR COUNTY MENTAL HEALTH CENTER TO RELEASE TO AND
OR OBTAIN FROM
____________________________________
,
: ___________________________
/
:
IF INDIVIDUAL
RELATIONSHIP TO PATIENT
INDIVIDUAL
ORGANIZATION
______________________________________________________________
:
: __________________________________________
ADDRESS
CITY
/
: ___________________________
: ____________________________
: _____________________________
STATE
ZIP
PHONE NUMBER
FACSIMILE NUMBER
:
THE FOLLOWING INFORMATION AS IS MINIMALLY NECESSARY
(
/
)
PATIENT
LEGAL REPRESENTATIVE INITIAL APPROPRIATE BLANK
:
RELEASE TO
:
OBTAIN FROM
,
,
SUMMARY OF TREATMENT TO INCLUDE DATES OF CONTACT
DIAGNOSIS
,
,
SUMMARY OF TREATMENT TO INCLUDE DATES OF CONTACT
DIAGNOSIS
,
,
,
PROGNOSIS
TREATMENT PLAN
ADMISSION EVALUATION
DISCHARGE
,
,
,
PROGNOSIS
TREATMENT PLAN
ADMISSION EVALUATION
DISCHARGE
,
,
,
SUMMARY
MEDICAL PROGRESS NOTES
PSYCHIATRIC EVALUATION REPORT
,
,
SUMMARY
MEDICAL PROGRESS NOTES
PSYCHIATRIC EVALUATION
PSYCHOLOGICAL EVALUATION REPORT AND RECOMMENDATIONS
,
REPORT
PSYCHOLOGICAL EVALUATION REPORT AND
RECOMMENDATIONS
/
,
,
,
/
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,
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ALCOHOL
DRUG TREATMENT PROGRESS
KCPC
EVALUATION
ALCOHOL
DRUG TREATMENT PROGRESS
KCPC
EVALUATION
TREATMENT
,
,
TREATMENT PLAN
DISCHARGE SUMMARY
PLAN
DISCHARGE SUMMARY
PSYCHOTHERAPY PROGRESS NOTES
MEDICAL RECORDS
CURRENT NEEDS AND FUNCTIONING LEVEL
SCHOOL REPORT REGARDING GRADES AND CONDUCT
D
L
T
: (E
: A
, B
,
ISCLOSURE
IMITED
O
X
PPOINTMENTS
ILLING
(
):
OTHER
SPECIFY
A
, D
)
CKNOWLEDGMENT OF SERVICES
IAGNOSIS
:
THE PURPOSE OR NEED IS TO
(
/
)
PATIENT
LEGAL REPRESENTATIVE INITIAL APPROPRIATE BLANK
(
)
,
TO ASSIST THE PERSON
S
OR ORGANIZATION TO WHOM THE
TO OBTAIN INFORMATION IMPORTANT IN EVALUATION
TREATMENT AND
/
/
DISCLOSURE IS BEING MADE IN THEIR PROVISION OF SERVICES
CARE
SERVICE PROVISION
CARE COORDINATION
COORDINATION
(
):
OTHER
SPECIFY
(
):
OTHER
SPECIFY
.
THIS CONSENT TO DISCLOSE MAY BE REVOKED BY ME AT ANY TIME UPON MY WRITTEN REQUEST EXCEPT TO THE EXTENT ACTION HAS BEEN TAKEN IN RELIANCE THEREON
THIS CONSENT
. I
F
C
M
C
’
EXPIRES ONE YEAR FROM THE DATE SIGNED
UNDERSTAND AND ACCEPT THAT UPON
OUR
OUNTY
ENTAL HEALTH
ENTER
S RECEIPT OF THIS WRITTEN REQUEST FOR REVOCATION
.
THE REQUEST WILL BE MADE EFFECTIVE NO LATER THAN THE END OF THE NEXT BUSINESS DAY
(
): ___________________________________________________________________
OTHER
SPECIFY DATE OR EVENT IF RELEASE TO EXPIRE IN LESS THAN ONE YEAR
(
/
)
PATIENT
LEGAL REPRESENTATIVE INITIAL
(
):
PRINTED NAME OF PERSON AUTHORIZING THE RELEASE
PATIENT OR AUTHORIZED REPRESENTATIVE
:
:
PATIENT SIGNATURE
DATE
/
/
/
/
:
/
:
:
PARENT
GUARDIAN
LEGAL REPRESENTATIVE SIGNATURE
ADDRESS
PHONE
DATE
/
/
:
RELATIONSHIP
(
)
-
:
:
WITNESS SIGNATURE
DATE
/
/
**
,
,
**
PLEASE READ THE ENTIRE FORM
BOTH FRONT AND BACK PAGES
BEFORE SIGNING
- 1
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REVISION: JANUARY 2016
080
BLANK FORM
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