SPECIAL AUTHORIZATION FOR RELEASE OF MENTAL HEALTH,
SUBSTANCE ABUSE , HIV-RELATED AND/OR GENETIC TESTING INFORMATION
Name of Patient:______________________________
Date of Birth: ________________________________
Social Security Number:________________________
I,___________________________, authorize healthcare practitioners and facilities that have provided medical treatment, evaluation, testing, rehabilitation or consultation to release to __________, and any authorized agent, representative or subcontractor of ____________, copies of any and all medical records and information in their possession, including information related to the patient past or present evaluation, diagnosis or treatment of
_____ Mental health,
_____ Substance abuse,
_____ HIV-related treatment, and/or
_____ Genetic testing.
I authorize __________, its agents representatives or subcontractors to use this information and disclose it as necessary for the purposes of evaluating and processing claims by the patient for benefits.
I understand that refusal to grant consent to release of psychiatric information will not jeopardize the patient's right to obtain present or future treatment except where disclosure is necessary for the treatment.
This authorization is subject to revocation at any time, except to the extent that action has been taken in reliance thereon.
This authorization is valid for 180 days after the date appearing below or 90 days after the patient's final episode of service, whichever is later. A copy of this authorization is as valid as the original.
____________________________ ________________
Signature of patient or person granting
Witness
authorization on behalf of patient
____________________________
________________
Relationship of person signing
Date
authorization
if other than patient