Confidential Exchange Of Information Form
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3CONFIDENTIAL EXCHANGE OF INFORMATION FORM
Optum requires contracted behavioral health practitioners and facilities to coordinate treatment with other behavioral
health practitioners, primary care physicians (PCPs), and other appropriate medical practitioners involved in a
member’s care. Please complete this form and send it to the appropriate care provider(s) treating the member.
PATIENT NAME:
DOB:
A. Treating Behavioral Health Clinician/Facility Information:
Name:
Phone:
Address:
Fax:
B. PCP/Medical Practitioner or Other Behavioral Health Practitioner/Facility Information:
Name:
Phone:
Address:
Fax:
C. Patient Clinical Information:
1.
The patient is being treated for the following behavioral health condition(s):
ADHD/ Behavior Disorder
Substance Abuse
Psychotic Disorder
Bipolar Disorder
Depressive Disorder
Anxiety Disorder
Eating Disorder
Adjustment Disorder
Personality Disorder
Other: ___________________________________________________________________
2.
The patient is taking the following prescribed psychotropic medication(s):
Antidepressant
Name:
Dose:
Frequency:
Mood Stabilizer
Name:
Dose:
Frequency:
Stimulant
Name:
Dose:
Frequency:
Anxiolytic
Name:
Dose:
Frequency:
Antipsychotic
Name:
Dose:
Frequency:
Other (Indicate medication name):_________________________________________________________________________
3.
Expected length of treatment: <3 months
3-6 months
6-12 months
>1 year
4.
Coordination of care issues/Other relevant information impacting care: ____________________________________________
_________________________________________________________________________________________________________________
Date Mailed or Faxed to Other Practitioner/Facility:
___________________________________________________
(PLACE A COMPLETED COPY OF THIS FORM IN THE PATIENT’S MEDICAL RECORD)
I hereby freely, voluntarily and without coercion, authorize the behavioral health practitioner listed above in Section A to release the
information contained on this form to the practitioner/provider listed in section B above. The reason for disclosure is to facilitate
continuity and coordination of treatment. This consent will last one year from the date signed. I understand that I may revoke my
consent at any time.
_____________________________________________________________________
__________________________________
Patient Signature
Date
I do not want to have information shared with:
My PCP/Medical practitioner
I am not currently receiving services from a PCP/ other medical practitioner
My other behavioral health practitioner(s)
I am not currently receiving services from any other behavioral health practitioner
______________________________________________________________
______________________________
Behavioral Health Practitioner/Facility Representative Signature
Date
For Patient Records Applicable Under Federal Law 42 CFR Part 2
To the party receiving this information: This information has been disclosed to you from records whose confidentiality is protected by
federal law. Federal regulations (42) CFR Part 2 prohibit you from making any further disclosure of it without the specific written consent of the
person to whom it pertains, or as otherwise permitted by such regulations. A general authorization for the release of medical or other
information is not sufficient for this purpose.
THIS IS NOT A REQUEST FOR MEDICAL RECORDS
United Behavioral Health operating under the brand Optum
U.S. Behavioral Health Plan, California doing business as OptumHealth Behavioral Solutions of California
BH809_12.6.16
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