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 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:

    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.