Authorization for Disclosing And/Or Requestingor Using Health Information
Authorization for Disclosing and/or Requestingor Using Health Information
I,______, hereby authorize Henrico Area Mental Health and Retardation Services or ______to disclose/request/use the following health information for the purpose listed below or to disclose the following information to/from the person/agency listed below: Check the appropriate item(s)
DISCLOSE/SEND TO THE FOLLOWING PERSON/AGENCY: / CHECK N/A IF NOT DISCLOSING INFORMATION N/APRINT NAME OF PERSON OR AGENCY
PERSON/AGENCY’S PHONE # STREET ADDRESS CITY STATE ZIP
Audiology Report / General Health Physical / PIP Family Services Plan / Social History / Other: (Specify):
Case Closing Summary / Infant Screening Results / Psychological Evaluation / Substance Abuse Information
Diagnosis / Infectious Disease: AIDS, HIV, TB / Progress Notes / Summary of Service received
Employment History & Performance / Intake/Referral/Screening / Summary of participation & attendance / Treatment Plan
Evaluation/Assessment / Medication(s) Prescribed
REQUEST/RECEIVE FROM THE FOLLOWING PERSON/AGENCY: / CHECK N/A IF NOT REQUESTING INFORMATION N/A
PRINT NAME OF PERSON OR AGENCY
PERSON/AGENCY’S PHONE # STREET ADDRESS CITY STATE ZIP
Audiology Report / General Health Physical / PIP Family Services Plan / Social History / Other: (Specify):
Case Closing Summary / Infant Screening Results / Psychological Evaluation / Substance Abuse Information
Diagnosis / Infectious Disease: AIDS, HIV, TB / Progress Notes / Summary of Service received
Employment History & Performance / Intake/Referral/Screening / Summary of participation & attendance / Treatment Plan
Evaluation/Assessment / Medication(s) Prescribed
Check all that apply
METHODS PERMITTED TO DISCLOSE OR REQUEST HEALTH INFORMATION: / written oral fax
Assessment / On-going Treatment
PURPOSE FOR WHICH THIS INFORMATION IS TO BE USED IS: / Follow - up Care / Other: Specify):
As the person signing this authorization, I understand that I am giving my permission to the above named provider to use, or disclose and/or request confidential health care records. I may refuse to sign the authorization and treatment or payment will not be conditioned upon my willingness to sign this authorization. Treatment, payment, healthcare operations or eligibility are not conditional upon giving authorization. The original or a copy of this authorization and a notation concerning the persons or agencies to whom disclosure was made shall be included with my original records. The person who receives the records to which this authorization pertains may not redisclose them to anyone else without my separate written authorization unless such recipient is a provider who makes a disclosure permitted by law. I also understand that I have the right to revoke this authorization at any time, but not retroactive to information already released in accordance with the authorization. My revocation is not effective until delivered in writing to the person who is in possession of my records. This authorization is automatically revoked upon termination of service.
If not previously revoked, this authorization will terminate: this authorization is effective beginning:
in: / 90 Days, / 365 Days (one year), or / upon the following date, event or condition:
Client Signature / Date Signed / Date of Birth / Last 4 digits of SS# / Case #
______
Client’s Parent, or Legal Guardian or Legal Representative Signature / Date Signed / Authority of Legal Representative
This information has been disclosed to you from records whose confidentiality is protected by state and/or federal law. State and federal laws may not prohibit the receiving person or agency from making any further disclosure ofredisclosing this information. However, without the specific written authorization of the person to whom it pertains, or as otherwise permitted by law or regulation A general authorization for the release of medical or other information is NOT sufficient authorization. Federal Regulations (42 CFR Part 2), restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patientspecifically prohibit redisclosure of records disclosed from alcohol or substance abuse treatment programs except with the specific authorization of the individual who is the subject of the records..
SEND TO THE ATTENTION OF: / , Henrico Area Mental Health and Retardation Services
Cypress / Finlay / Henrico Co. Regional Jail - East / Lakeside House / Radford / Woodman-MR
101-A Roxbury Industrial Center / 4796 Finlay Avenue / 17320 New Kent Highway / 5623 Lakeside Avenue / 4915 Radford Avenue / 10299 Woodman Road
Charles City, Virginia 23030
/ Richmond, Virginia 23231 / Barhamsville, Virginia 23011-2354 / Richmond, Virginia 23231 / Richmond, Virginia 23228 / Glen Allen, Virginia 23060TEL: (804) 966-5723 / TEL: (804) 222-4855 / TEL: (804) 652-1250, 1255 / TEL: (804) 264-1007 / TEL: (804) 359-3370 / TEL: (804) 261-8513
East / Hermitage Enterprises / Henrico Co. Jail - West / Providence Forge / Woodman-ACT / Woodman-PIP
4825 South Laburnum Avenue / 8247 Hermitage Road / Box 27032 4301 East Parham Road / 9403 Pocahontas Trail / 10299 Woodman Road / 10299 Woodman Road
Richmond, Virginia 23231 / Richmond, Virginia 23228 / Richmond, Virginia 23273 / Providence Forge, Virginia 23140 / Glen Allen, Virginia 23060 / Glen Allen, Virginia 23060
TEL: (804)222-2607 / TEL: (804) 262-6665 / TEL: (804) 501-4580, 4586, 4590 / TEL: (804) 966-5959 / TEL: (804) 261-8442 / TEL: (804) 261-8548
Enterprise Parkway / Juvenile Detention Home / Woodman-Central / (Other)
2715 Enterprise Parkway / P.O. Box 27032 / 10299 Woodman Road
Richmond, Virginia 23294 / Richmond, Virginia 23273-7032 / Glen Allen, Virginia 23060
TEL: (804) 217-9601 / TEL: (804) 501-5748 / TEL: (804) 261-8500
Keep a copy of authorization in chart
Revised 1/1/03 HAMHRS #007 REC