Authorization/Denial to Obtain or Release Information and Records
Attention: _______________________________________________
Resident Name: __________________________________________________
D.O.B.: _________________________
OBTAIN: I, ___________________________________________________________(Resident/Guardian if
resident is a minor) authorize ________________________________________ (Name of program) by fax or mail, to
obtain information including medical and/or mental health records from:
(Name and telephone number of agency/school/physician)
(Complete mailing address of agency/school/physician)
RELEASE: I, ___________________________________________________________(Resident /Guardian if
Resident is a minor) authorize ________________________________________ (Name of program) via U.S. mail, to
release information including medical and/or mental health records to:
(Name and telephone number of agency/school/physician)
(Complete mailing address of agency/school/physician)
Dates of service: ____________________________________ (Fill in only if limiting the dates of records, otherwise
complete record will be sent.)
Please indicate the SPECIFIC information to be disclosed: (please complete each category)
Y N
Intake Assessment Summary (Clinical Interview)
Y N
Progress Notes
Y N
Service Plans
Y N
Discharge Summary
Y N
Medical Summaries
Y N
Psychiatric Summaries and
medications
Y N
School Information
Y N
Other _________________________
The purpose of this release of information is:
________Assist in service planning
_______ Coordination of care
________ Evaluation
________Other (specify) _____________________________________________________________________________
(signature required on next page)
CERTAIN PROTECTED CATEGORIES OF INFORMATION CANNOT BE RELEASED UNLESS THE NEXT
PAGE OF THIS FORM IS COMPLETED.
Formatted By:
F
S
M
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T
AMILY
HELTER
ODEL
ECORD
EAM
Sponsored by the Department of Public Health, Bureau of Substance Abuse Services
Facilitated by The Quality Improvement Collaborative