Behavioral Health Medical Records Request

AUTHORIZATION FOR DISCLOSURE OF MENTAL HEALTH INFORMATION AND CONFIDENTIAL SUBSTANCE ABUSE TREATMENT RECORDS
Released From:
Patient Name*
Formerly Known As
Patient's Date of Birth*

MonthDayYear
Date
Authorization for use and disclosure of mental health information: State and federal laws govern the confidentiality and protection of individually identifiable health information. Except in specific situations defined in various laws, protected health information may not be disclosed without written authorization.

Authorization for use and disclosure of substance abuse information: Substance abuse treatment records maintained by the Colorado Department of Human Services are confidential and will not be released, unless otherwise provided for by the regulations, without written consent from the individual or his or her personal representative.

I, First Name* Last Name* , authorize Gunnison Valley Health Behavioral Health to release mental health information and the substance abuse treatment information of the individual named below:

I authorize the information to be disclosed received or exchanged with the following individual(s) or organization(s). (When using a general designation, you have the right to obtain, upon request, a list of entities to whom your information has been disclosed, pursuant to the general designation.)
Name of Entity, Facility, Other Person, Self:*
Mailing Address*
City*
State*
Zip*
Phone*
Email
example@example.com
Fax
Please enter a valid fax number.
Purpose of Disclosure*

Continuity of CarePersonal UseLegalOther
Records/Information Needed

All of my substance use disorder information including concurrent mental health information ORDate of Service Range (month/year) from-to
Evaluations and assessmentsMedicationsPrescriber notesPsychotherapy notesCare/Treatment PlanSTI/HIV/AIDS information and recordsLab ResultsDischarge SummaryBilling statementsOther
Select Method of Delivery*

Paper Format Pickup (patient or other person only)Paper Format - U.S. MailSecure EmailFax
Revocation: This authorization may be revoked at any time, in writing. If not revoked sooner, this authorization will expire upon discharge from treatment or one (1) year from the date it was signed, which ever first occurs.
I understand that I might be denied services if I refuse to consent to a disclosure for purposes of treatment, payment,or health care operations, if permitted by law. I will not be denied services if I refuse to consent to a disclosure for otherpurposes. I have been provided a copy of this form
Signature of Patient/Guardian/Authorized Representative**

Clear
Relationship:
Date*

MonthDayYear
Authorized Representative's Legal Authority

Medical Durable Power of Attorney AgentHealthcare Proxy Decision MakerBenefactor of EstateGuardianParent of MinorConservatorSurrogate Decision Maker for Healthcare Benefits
* Signature by an authorized representative certifies such person has the legal authority to authorize the disclosure on behalf of the patient.
Notice Accompanying Disclosure

Prohibition on Re-disclosure of Confidential Information

This notice accompanies a disclosure of information concerning a patient in substance abuse treatment, made to you with the consent of such patient. This information will be disclosed from records protected by Federal confidentiality rules set forth in 42 CFR Part 2. The Federal rules prohibit any further disclosure of this information unless such further disclosure is expressly permitted by the written consent of the person to whom the records pertain or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information contained in these records to criminally investigate or prosecute any alcohol or drug abuse patient.

PLEASE ALLOW 10 BUSINESS DAYS TO FULFILL RECORDS REQUESTS.
Should be Empty:

AUTHORIZATION FOR DISCLOSURE OF MENTAL HEALTH INFORMATION AND CONFIDENTIAL SUBSTANCE ABUSE TREATMENT RECORDS

Released From: