CONSENT FOR RELEASING OR OBTAINING CONFIDENTIAL MEDICAL INFORMATION

Patient first name

Patient last name

Birthdate

I hereby freely and voluntarily authorize Behavioral Medical Center – Troy to:

Release/disclose my protected health information

Obtain my protected health information

PHYSICIAN/THERAPIST/PERSON RELEASING INFORMATION:

Name

Other Person:

Address

City

State

Zip

Phone Number

FAX Number

PHYSICIAN/THERAPIST/PERSON RECEIVING INFORMATION:

Name

Address

City

State

Zip

Phone Number

FAX Number

Email Address

I understand that my medical records may contain information regarding testing, drug and/or alcohol diagnosis and treatment, a communicable or venereal disease which may include, but is not limited to diseases such as hepatitis, syphilis, gonorrhea or the human immunodeficiency virus, also known as acquired immune deficiency syndrome (AIDS) and/or tuberculosis. I understand that such information is confidential and is protected by federal law. I understand that the provision of health care treatment to me cannot be conditioned upon my agreement to sign an authorization for the disclosure or use of my health information for purposes other than for treatment, payment, and healthcare operations. I understand that the potential exists for health information that is released with my authorization to be re-disclosed by the recipient, and to be no longer protected by the federal HIPPA law. I understand that I have the right to revoke this authorization at any time by giving written notice to the Privacy Officer at Behavioral Medical Center – Troy, except to the extent that action has already been taken in reliance on it. If not previously revoked by me in writing, this authorization is effective on this date and will expire one (1) year following discharge from treatment.

INFORMATION TO BE USED OR DISCLOSED

Psychological Intake

Complete Records

Medication Reviews

Progress Report

Psychological Screening

Treatment Plan

Psychological Testing

Diagnosis

Therapy Notes

Other

PURPOSE OF DISCLOSURE

Insurance Matters

Progress Updates

Academic Matters

Referral for Services

Legal Matters

Coordination/Continuation of Care

Patient Request

Other

Patient or Parent/Guardian Signature

Date: