Hipaa Authorization To Disclose Protected Health Information Mental Health Records

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HIPAA
AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION
MENTAL HEALTH RECORDS
Patient name: ____________________ D.O.B.: ___/___/___ S.S.N.: _____________
Dates of Treatment: beginning _______ through ________
[relevant time period must be inserted]
AUTHORIZATION:
I, _____________________________________, authorize the disclosure of my protected
health information as described herein.
I authorize the following person(s) and/or organization(s) to disclose the protected
1.
health information described in paragraph 3.
[individual medical provider name must be inserted]
I authorize the following person(s) and/or organization(s) to receive the protected
2.
health information described in paragraph 3.
[individual firm or lawyer must be inserted]
The records authorized to be released include:
3.
[ ] complete copy of medical records
[ ] test results
[ ] other
USDC, DNM Local Form 2, Page 1 (amended 11/05/04)

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