Authorization To Use And Disclose Health Information Form (Page 2 of 2) in pdf

AUTHORIZATION TO USE AND DISCLOSE HEALTH INFORMATION

Page 2



Unless specifically restricted or limited, the protected health information used or disclosed may include

information related to behavioral and mental health services and evaluation and treatment for alcohol

or drug abuse. * If the person or organization to which this information is disclosed is not a health plan

or health care provider, or if the information does not relate to a federally-funded substance abuse

program, the information may no longer be protected by federal privacy law and regulations after

disclosure. In that case, the person or organization receiving it may redisclose the information.



I may revoke this authorization at any time, by presenting my written revocation to Educational &

Psychological Services, Ltd. However, my revocation will not be effective for uses or disclosures that

have already been made, or other actions that have already been taken, in reliance on this authorization

or as required by law.



This authorization expires on (specify date) _______________. For mental health records, if no date is

specified, this authorization is effective only on the date signed. For all other records, if no expiration

date is specified this authorization shall be effective for 90 days after the date of my signing below,

unless revoked by me sooner, or limited or restricted to a shorter time by applicable law.



I am entitled to inspect and copy any information that is used or disclosed based upon this

authorization. I am also entitled to a copy of this authorization after signing below.

I ACCEPT THESE TERMS AND AUTHORIZE THE ABOVE USE AND DISCLOSURE:

__________________________________________________

_______________

Signature of Patient or Legally Authorized Representative

Date

_________________________________________________________________

If not Patient, then Relationship of Legally Authorized Representative to Patient

_____________________________________________________

_________________

Signature of Witness

Date

*Notice to Recipients of Alcohol & Drug Abuse Information: The confidentiality of alcohol and drug

abuse patient records maintained by Educational & Psychological Services, Ltd. and disclosed to you

pursuant to this authorization, is protected by Federal law and regulations and by the Illinois Mental Health

and Developmental Disabilities Confidentiality Act. Generally, you may not further disclose the identity of

the patient, or any information identifying the patient as an alcohol or drug abuser, or recipient of mental

health services unless: (a) the patient consents in writing; (b) the disclosure is allowed by a court order; or

research, audit, or program evaluation purposes. Violation of Federal laws or regulations is a crime.

Authorization To Use And Disclose Health Information Form Page 2