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Julie Racine PMHNP-BC

Psychiatric Mental Health Nurse Practitioner

AUTHORIZATION TO DISCLOSE CONFIDENTIAL INFORMATION

_______________________________________________________________________________________________________________________________________

Name of Client:

_______ DOB:

_____________ Client:

___________

I hereby authorize Sweetser, its authorized employees and agents to: (Check all appropriate boxes)

Obtain written medical/clinical records:

Disclose written medical/ clinical records:

verbally discuss:

Organization/Individual:

Relationship:

Street Address:

Phone #:

City/State/Zip:

Fax #:

This authorization applies to all Sweetser programs that I am currently enrolled in or have been enrolled in unless program

exclusion is noted: DO NOT release information from following noted program(s):

The medical/clinical records and information include the following: (mark with X only those items to be disclosed)

Treatment Plan

Psychological Testing

Discharge Summary

Psychiatric Evaluation

Progress Notes

Medical Information (including Labs, Med List)

Crisis Intervention Assessment

Diagnoses

Comprehensive Assessment

Other Records (be specific):

The records and information are to be provided or obtained for purposes of: (Place an X next to all appropriate responses)

Ongoing Treatment

Educational

Financial

To coordinate treatment efforts

Aftercare Treatment

Legal

Other (be specific):

I DO

I DO NOT

Authorize information which refers to treatment or diagnosis of alcohol or drug abuse to be disclosed or

obtained.

IMPORTANT: If checked “I DO”, then the client MUST sign this consent, regardless of age) I understand my alcohol and substance abuse

record is protected under Federal Regulation, 42 C.F.R. Part 2, which prohibits these records from being disclosed or re-disclosed without

written consent, unless otherwise provided in Regulations. While the Federal Regulations protects information from being re-disclosed I

understand that Sweetser can not guarantee that the recipient will not rte-disclose this information to a third party.

I DO

I DO NOT authorize information concerning diagnosis and treatment of mental health conditions to be disclosed or obtained.

I DO

I DO NOT authorize information which refers to treatment or diagnosis of HIV infection or AIDS to be disclosed or obtained.

I DO

I DO NOT wish to review written information prior to its being disclosed. (No X is needed for Verbal communications)

I DO

I DO NOT want a copy of this consent.

The records and information are to be provided or obtained for purposes of: (Check all appropriate boxes)

Educational

Ongoing/ Aftercare Treatment

Financial

To coordinate treatment efforts

Legal

Other (be specific)

_____________

I understand that

I can refuse to disclose some or all of the information in my treatment records, but if I do so, it could result in an improper diagnosis or

•

treatment, or a denial of coverage or of a claim for health benefits/other insurance, or other adverse consequences.

Sweetser’s provision of services does not depend on my giving this consent, except that my refusing consent connected with a research project

•

may result in my not receiving treatment as a participant in that project.

Any records and information disclosed to a recipient outside Sweetser may potentially be re-disclosed and no longer be protected by Federal or

•

State law.

I may revoke this authorization at any time either verbally or in writing. A revocation does not apply to any actions previously taken in reliance

•

on my consent, including disclosures already made or services already rendered.

This consent is effective until

(Maximum is one year for mental health services, six months for children in residential care

only, and ninety days for one-time disclosures).

I DO

I DO NOT authorize future disclosures regarding these records to the same

individual/ entity during this time period.

Signature of Client: __________________________________________________ Date: _______________________________

Signature of Parent/Guardian: _________________________________________ Date: ______________________________

Printed Name: _____________________________________________________

Staff Signature and Title: _____________________________________________ Date: ______________________________

Consents/Legal

7750 MR33 – REV 7-7-08

Authorization To Disclose Confidential Information Form - Maine Mental Health Services

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