Authorization For Release Of Mental Health Record printable pdf download

Mental Health & Counseling

PO Box 208237

New Haven, CT 06520-8237

Phone: 203-432-0290 Fax: 203-432-8458

AUTHORIZATION FOR RELEASE OF MENTAL HEALTH RECORD

(Also known as Protected Health Information)

PATIENT NAME _______________________________________

Date of Birth _______________

Address (Mailing) __________________________________

Phone ____________________

__________________________________

I authorize Yale Health Department of Mental Health & Counseling to use or disclose information from my mental

health record, which may include information about psychiatric diagnosis and treatment and substance abuse issues

to:

Name: ________________________________________ Phone _________________________

Address:______________________________________ FAX _________________________

______________________________________________________________________

Dates of Treatment: ____________________________________________________________

Information to be released (Please describe) _________________________________________

Purpose of Disclosure __________________________________________________________

1. I understand that, unless withdrawn, this authorization will expire 180 days from the date of signature. A photocopy of

this form will be considered as valid as the original.

2. I understand that I may revoke this authorization at any time by notifying the Department of Mental Health &

Counseling at the address indicated above, in writing, and this authorization will cease to be effective on the date

notified except to the extent action has already been taken in reliance upon it.

3. I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the

recipient and no longer be protected by Federal privacy regulations. However, other state or federal law may prohibit

the recipient from disclosing specially protected information, such as substance abuse treatment information and

mental health information.

4. I understand that my refusal to sign this Authorization will not jeopardize my right to obtain present or future

treatment for psychiatric disabilities except where disclosure of the information is necessary for the treatment.

5. My health care and payment for my health care at Yale Health Center will not be affected if I do not sign this form.

6. I understand that I can request a copy of this form after I sign it.

7. I understand that in compliance with CT general statute, I will pay a fee of $0.65 per page.

By signing below, I acknowledge that I have read and understand this Authorization.

_________________________________ _________ OR _____________________________________

________

Signature of Patient

Date

Parent/Legal Guardian/Authorized Person

Date

__________________________________

Relationship to Patient

Rev. 1/11

Authorization For Release Of Mental Health Record