Authorization For The Use Or Disclosure Of Health Information Page 2

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Authorization for the Use or Disclosure of Health Information
It is important for your health information to be shared with all of your health care providers to ensure that you receive the best
care possible. The purpose of sharing your health information with your providers or supports is to assist in identifying any
follow-up medical care that may be needed.
Please allow ValueOptions of Kansas and your treatment team to share your health information with each other by signing the
release of information below, or having a person who is legally authorized to act on your behalf sign. We will only send and
receive information that pertains to your care.
Member/Individual Name:
Member/Individual ID or Social Security Number:
Member/Individual Date of Birth:
Authorization for Disclosure of Health Information
Information to Which This Authorization Applies:
I hereby authorize the parties identified below to disclose
42 CFR regarding substance abuse confidentiality
(send and receive) my health information to the other
requires as limited information be disclosed as possible,
parties identified in this document for a period of six
please only check the box(es) that apply
months.
Physical and Mental Health
All health information pertaining to any medical history,
Name ___________________________________
mental or physical condition, and treatment received
Address _________________________________
(including services provided at a Community Mental
Phone __________________________________
Health Center and/or information related to HIV/AIDS
Fax ____________________________________
status) in the possession, custody or control of the
parties identified in this document, regardless of when
Name ___________________________________
such information was generated. This authorization
Address _________________________________
does not include substance abuse records.
Phone __________________________________
Fax ____________________________________
Substance Abuse
I specifically authorize the release of personal health
Name ___________________________________
information from my drug and alcohol assessment. The
recipient of drug and/or alcohol abuse information
Address _________________________________
disclosed as a result of this Authorization will need my
Phone __________________________________
further written authorization to re-disclose this
Fax ____________________________________
information. 42 CFR §2.32 restricts any use of this
information to criminally investigate or prosecute any
Name ___________________________________
alcohol or drug abuse patient. Initials:_____
Address _________________________________
Phone __________________________________
Specific Information
Fax ____________________________________
The following records or types of health information
(including any dates):
Information
Date Range
Name ___________________________________
_____________________
__________________
Address _________________________________
_____________________
__________________
Phone __________________________________
_____________________
__________________
Fax ____________________________________
Please cross through this page if not needed.
Page 2 of 4
Initials:_____ Date:_________
Revised February, 2010

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