Form Sbc 115 - Authorization To Release And Obtain Confidential Information
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1STRATEGIC BEHAVIORAL CENTER 3200 Waterfield Dr. Garner, NC 27529 ~Phone: 919-800-4400 ~ Fax: 919-573-4163
AUTHORIZATION TO RELEASE AND OBTAIN CONFIDENTIAL INFORMATION
Client’s Full Name: ___________________________________________
Date of Birth: _____/_____/_____
Medical Record # ____________________________________________
Social Security Number # __________________________________
AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFOMRATION – 45 CFR Parts 160 and 164; CFR,
Part 2; G.S. 122C This form implements the requirements for client authorizations to use and disclose health information protected by the
federal health privacy law (45 CFR parts 160, 164), the federal drug and alcohol confidentiality law (42 CFR part 2 and state confidentiality
law governing mental health, developmental disabilities and substance abuse services (G.S.122 C).
I, _________________________________________________________________ authorize _Strategic Behavioral Center _____________________
(Client’s name or client’s legally responsible person or personal representative)
(Agency or person authorized to use or disclose the information)
to obtain or disclose to ______________ ______________________________________________________________________________________
(Agency or person to whom the requested use or disclosure will be made)
________________________________________________________________________________________________________________________
(Address of Agency or person to whom the requested use or disclosure will be made)
TYPE OF INFORMATION TO BE OBTAINED OR DISCLOSED
This data shall include: (Client / Guardian Initials by EACH appropriate block)
_____ Dates of Treatment
_____ Diagnosis
_____ Financial Information
_____ Admission Assessment
_____ Case Management Assessment / Notes
_____ Insurance Information
_____ Alcohol / Drug History
_____ Psychological Evaluation
_____ IPRS
_____ Legal History
_____ Psychiatric Evaluation
_____ NC SNAP
_____ Person-centered Plans / Plans of Care
_____ Psychiatrists Progress Notes
_____ NC TOPPS
_____ Discharge Summary
_____ Medication History / Physician’s Orders
_____ Lab results: Specify type: _______________
_____ Verbal communication related to treatment
_____ School (attendance, grades, IEP, education)
_____ Other: (Specify) ____________________
I understand this information will be used for: (Client / Guardian Initials by EACH appropriate block)
_____ Insurance / Medicaid / Medicare / IPRS determinations of benefits and billing purposes
_____ To assist in the development of individual service / goals plans
_____ To assist in securing benefits from entitlement programs
_____ Provide data to assist with evaluation / assessment / prescriptive services
_____ Coordination of services between agencies
_____ Other: (Specify) ______________________________________________________________________
AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION 45 CFR Parts of 160 and 164: 42 CFR,
Part 2: G.8. 122C I understand that the information to be released may include information regarding drug abuse, alcohol abuse, sexually
transmitted diseases, HIV Infection, AIDS or AIDS related conditions, psychiatric information or physical impairments.
REVOCATION AND EXPIRATION
I understand that, with certain exceptions, I have the right to revoke this authorization at any time, except to the extent that action has been
taken in reliance on it. The procedure for how I may revoke this authorization, as well as the exceptions to my right to revoke, are explained
in STRATEGIC BEHAVIORAL CENTERS Privacy Notice, a copy of which has been provided to me.
If not revoked earlier, this authorization expires automatically upon: __________________ or one year from the date it is signed, whichever is earlier
NOTICE OF VOLUNTARINESS
I certify that this authorization is made freely, voluntarily and without coercion. I understand that STRATEGIC BEHAVIORAL CENTER
cannot deny or refuse to provide treatment, payment, enrollment in a health plan or eligibility for benefits if I refuse to sign this
authorization, except in limited circumstances, i.e. research related treatment, services provided solely for reason of creating PHI for
rd
disclosure to a third (3
) party.
Signature: ___________________________________________________________________________
Date: ___________________________
Please explain authority of person signing above to act on behalf of client:__________________________________________________________
Signature of MINOR: __________________________________________________________________
Date: ___________________________
OSIS)
(MINORS SIGNATURE ONLY REQUIRED IF MINOR HAS A SUBSTANCE ABUSE DIAGN
SBC 115 – Consent for Release of Information-Disclosure RV041811
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