Healthcare DBT ROI Form

Healthcare DBT ROI Form

Authorization to Use and Disclose Protected Health Information

I authorize the use or disclosure of my protected health information as described below. I understand that this authorization is voluntary and that I may revoke it at any time in writing, except to the extent that action has already been taken in reliance on this authorization. I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer protected by applicable privacy rules.

Patient Information

Recipient / Organization to Receive Information

Purpose of Disclosure

The purpose of this disclosure is (check all that apply):

Continuity of care / coordination between providers
Insurance, payment, or claim processing
Legal / court-related
Personal / at my request
Research (if applicable, only non-identifying information will be released unless authorized)
Other (describe):

Specific Information to Be Released

Check all categories of information to be disclosed. Psychotherapy notes require separate specific authorization; if psychotherapy notes are authorized, the patient must initial below where indicated.

Intake assessment and diagnosis
Progress notes and session notes
Treatment plan and goals
Medication records and prescription history
Billing statements and claims information
Laboratory and test results
Discharge summary
Other records (specify):

Psychotherapy notes (notes recorded by a mental health professional documenting or analyzing the contents of a counseling session that are maintained separately from the medical or mental health record) are treated as highly confidential. I authorize release of psychotherapy notes:

Yes — Release psychotherapy notes
Initials:

Date Range for Records

From:    To:

Method of Disclosure

Records may be released via the following methods (check all approved):

Postal mail
Fax
Unsecured email (I understand there are risks of interception)
Secure electronic portal
Verbal disclosure by phone

Expiration and Revocation

This authorization will expire on: . If no date is provided, this authorization expires one year from the date of my signature unless otherwise prohibited by law.

I understand that I may revoke this authorization at any time by submitting a written revocation to the releasing provider, except to the extent that the provider has already acted in reliance on the authorization. Revocation will not affect information already released under this authorization.

Rights and Important Notices

• I understand that signing this authorization is voluntary and that my refusal to sign will not affect my ability to obtain treatment or payment, except where allowed by law.

• I understand that I have a right to inspect and copy the information to be used or disclosed as permitted by law, and I may request a copy of this signed authorization.

• I understand that the recipient may condition treatment, enrollment, or eligibility for benefits on whether I sign this authorization only if allowed by law. If I authorize release for insurance purposes, the recipient may have a right to access PHI necessary to process the claim.

• I understand that fees may be charged for copying and mailing records consistent with applicable law.

Acknowledgment

By signing below I authorize the release of protected health information as specified above. I have read and understand the terms of this authorization and I am signing voluntarily.

HIPAA Privacy Acknowledgment: I acknowledge that I have been provided or offered the provider's Notice of Privacy Practices explaining how my health information may be used and disclosed.

If person signing is not the patient, indicate relationship and authority to sign:

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