RELEASE FOR CONFIDENTIAL INFORMATION
FROM THE RECORD OF:
Name:
Birthdate:
I hereby authorize all Lakeshore Regional Partners, Community Mental Health Services Programs (CMHSP) and their provider networks to release information contained in the clinical record concerning my service history to each other as is necessary for the purpose of coordinating my care and providing the treatment supports and services that I need. Collaboration between all providers involved in my treatment ensures continuity of care and can improve the quality of my supports and services.
I understand that my medical records may include alcohol and drug abuse information protected under 42 CFR Part 2. I authorize the release of this information as is necessary for the coordination of treatment. Initials
I understand that I may access a list of current LRP system providers at any time on the LRP website at .I may also request a current list from my service provider at any time. I understand that this list may periodically be modified and that I will be notified if a new provider is added to the list.
Information to be released may include screenings, assessments, case notes, treatment history, discharge records, and any other physical or clinical information that is contained in my electronic clinical record.
This authorization to release information is voluntary. I understand that my continued or future treatment is not conditioned upon my providing or signing this release.
This release may be revoked orally or in writing at any time except to the extent that action has already been taken in reliance on it. This authorization shall remain effective only so long as is necessary to fulfill the purpose of the disclosure, but no later than one (1) year from the original date of signing, unless previously revoked.
I acknowledge that the recipient of the released information could redisclose it to someone else, causing it to lose its protection under the Health Insurance Portability and Accountability Act of 1996, even if I did not authorize that redisclosure.
I had the opportunity to have this form explained to me and have my questions answered. I understand that I may request a copy of this release.
Signature: ______Date: ______
Self Parent/Guardian/Legal Representative
Signature: ______Date: ______
Witness
Information contained in the medical record may include mental health treatment, alcohol or drug abuse treatment, Human Immunodeficiency Virus, AIDS or other communicable disease status. This information is confidential and is protected by the Michigan Mental Health Code, Public Act 258 of 1974 as amended Section 748 (3); Public Health Code, Act 368 of 1978; Title 42 of the Code of Federal Regulations (CFR) Part 2; and the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule, located at 45 CFR, Parts 160 & 164. The released information may not be copied, shared or released except as consistent with the authorized purpose stated above.