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