Form Sd Eform - 2367 V1 - Consent For Information Disclosure - Department Of Social Services, State Of South Dakota
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1SD EForm - 2367
V1
Complete and use the button at the end to print for mailing.
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CONSENT FOR INFORMATION DISCLOSURE
I, _____________________________________________________, hereby authorize the exchange of information between
____________________________and the SD DEPARTMENT OF SOCIAL SERVICES, DIVISION OF COMMUNITY BEHAVIORAL
HEALTH and the re-disclosure of that information by __________________________and the SD Division of Community Behavioral
Health to:
DSS Division of Medical Services for Medicaid information
South Dakota Foundation for Medical Care for PRTF Admission
South Dakota Department of Health
DSS Division of Correctional Behavioral Health
South Dakota Department of Corrections or Juvenile Corrections Agent _____________________________________________
Unified Judicial System or Court Services Officer, ______________________________________________________________
My parents and/or legal guardian and/or prospective foster parents________________________________________________
Mountain Plains Research for purpose of reporting required demographic informatio
Law Enforcement Officials (City and/or County)
My current and/or former educational institution for purpose of obtaining academic information
The designated accredited alcohol and drug treatment provider and/or funding source necessary to facilitate my entry
into chemical dependency treatment or services.
Physician, IHS, and/or Medical Clinic/Facility _________________________________________________________________
Other ________________________________________________________________________________________________
Other ________________________________________________________________________________________________
Purpose of and need for the disclosure is to inform the person(s) or agency(ies) listed above of my:
Treatment Needs Assessment and DSS Approval Form
Diagnosis and Treatment Recommendations
Eligibility for treatment services
Financial Information and Funding Sources
Medical, dental, and/or eye care information and/or eligibility
Treatment Plan and/or Continued Care Reviews
Attendance, cooperation, and progress in treatment
Discharge Summary and/or Aftercare Plans
Group data for reports to evaluate outcome of treatment
Education Information
Legal Information
Other (be specific): ______________________________________________________________________
The above information will be used for the following: To provide the above noted individuals with information requested as noted
above, about the individual named above, to coordinate all available information to ensure placement in the appropriate level of care,
to ensure adequate funding, determine the diagnosis, course of treatment, follow-up, or need for other services, to ensure a full
continuum of care and to ensure quality services.
I understand that some or all of this information may at times be communicated via electronic transmission.
I also understand that I may revoke this consent in writing at any time, except to the extent that action has been taken in reliance on it, by
signing the revocation section of my copy of this form and returning it to __________________at _______________. In any event, this
consent will expire automatically as follows:
One year after this consent form is signed OR
______________________________________________________________________________________________________.
(Specification of the date, event or condition upon which this consent expires)
I also understand that my alcohol and/or treatment records are protected under the federal regulations governing Confidentiality of Alcohol
and Drug Abuse Patient Records, 42 C.F.R. Part 2, the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F. R. Pts.
160 & 164, and 42 U.S.C. §§ 290 dd-2 and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I
also understand that recipients of this information may redisclose it only in connection with their official duties.
Dated: _______________________ Client Signature: ______________________________________________________________
Witness Signature: ________________________________________________________
REVOCATION SECTION
I hereby revoke this consent
__________________________________________
____________________________________________
(Signature)
(Date)
Revised 09/11
PRINT FOR MAILING
CLEAR FORM
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