Authorization to use and disclose protected health information

1. I am completing this form to allow the use and sharing of protected health information about

2. I authorize StressCare Behavioral Health to obtain, use, or disclose the following
Information:

  • Information from StressCare Behavioral Health, including initial assessments,
    evaluation reports, progress notes, treatment plans, treatment and discharge summaries,
    or similar records.
  • Information about how the patient’s condition affects his or her ability to work or function.

3. Dates of care included:

4. To the following person or organization who referred me:

5. The information will be used/disclosed for the following purposes:

  • Treatment coordination
  • Evaluation Results

6. I understand and agree that this Authorization will be valid and in effect until the end of treatment or:

I understand that after the date or event, no more of this information can be used or released to the person or organization unless I sign a new Authorization like this one.

7. I understand that I can revoke or cancel this authorization at any time by sending a letter to the Privacy Officer of the organization listed above and which is to supply this information. If I do this, it will prevent any releases after the date it is received but cannot change the fact that some information may have been sent or shared before that date.

8. I understand that I do not have to sign this authorization and that my refusal to sign will not affect my abilities to obtain treatment from the professional or facility listed at number 2 above, nor will it affect my eligibility of benefits.

9. I understand that I may inspect and have a copy of the health information described in this authorization. If I request a copy of this information, I understand I will be charged $20 for the first fifteen (15) pages and $0.90 for each additional page.

10. I understand that if the person or entity that receives the information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be disclosed and no longer protected by those regulations

11. I understand that this professional or facility will receive compensation for the use or disclosure of my health information. The arrangement has been explained to me and I understand all of it. Does not apply

12.I affirm that everything in this form that was not clear to me has been explained and I believe I now understand all of it.