Authorization to Disclose Health Information

Client Name *

I authorize the use or disclosure of the above-named individual's health information as described below:

A. The following individual or organization is authorized to:

Release the informationReceive and use the information

Individual/Organization Name *

Street Address *

Apartment, suite, etc

City *

State *

ZIP / Postal Code *

Phone *

Fax *

B. The following individual or organization is authorized to:

Maryland Psychiatric Care, LLC
3050 Crain Highway
Waldorf, MD 20601

Release the informationReceive and use the information

C. The purpose(s) for which the information may be released:

Purpose *At the request of the patientContinuation of care/consultationSocial Security/Disability CertificationTo pass on message to the patient; determine the patient's locationTo exchange information concerning the patient illness and treatmentOther

D. If not previously revoked, this authorization will terminate on the earliest of the following dates:

One year from the signatures date below, or upon the following date, event, or condition:For authorizations to terminate due to an event or condition, the parties authorized to release information above must be notified in writing upon occurrence of the event or condition to cancel authorization.

Psychotherapy Notes (Due to the highly sensitive nature of psychotherapy notes federal law requires a separate authorization form for their disclosure.)

E. Dates of information (it applicable):

From Date

To Date

F. In understand the following:

A copy of this authorization is available to me, or to my authorized representative, upon request and will serve as the original.

Revocation: I have the right to revoke this authorization at any time. If I choose to cancel the release of information/authorization, I must notify the person/company identified in Section B in writing that I revoke this authorization. The revocation will not apply to information that has already been released in response to this authorization.

Re-disclosure: If this information is to be received by individuals or organizations that are not health care providers, health care clearing houses, or health plans covered by federal privacy regulations, my information described above may be re-disclosed and no longer protected by federal privacy regulations. Once information has been disclosed, it may no longer be protected from further disclosures by federal or state privacy laws.

Conditioning of eligibility: MPC Behavioral Health will not withhold treatment from me if I refuse to sign this form.

G. Signature

Signature *

Patient, Parent, or legal Guardian

Date *

Authorizations signed by a legal representative must include a copy of the Guardianship papers or a Power of Attorney.
Witness (if client is unable to sign):

Signature

Date

Authorization to Disclose Health Information Release of Information