Authorization to Release Protected Health and Behavioral Protected Health Information

Authorization to Release Protected Health and Behavioral Protected Health Information

Client Infomation

Client First Name *

Client Last Name *

Client Date of Birth * +

Agency and Release Information

I do hereby consent to authorize Diversus Health to (check all that apply) *

Release to Agency or Individual listed below

Request from Agency or Individual listed below

All my treating providers, staff, or representative at
Enter the name of the agency or individual you authorize us to share information with *

0/50 characters

Agency / Individual Mailing Address
Enter the name of the agency or individual you authorize us to share information with *

0/250 characters

Agency or Individual
Phone Number *

Agency
Fax Number (if applicable)

Agency / individual email address (if applicable)
Enter the name of the agency or individual you authorize us to share information with

Transmission Modes (How records may be released) check all that apply *

Electronic (Secure Email, Fax, CD, Upload)

Verbal

Written

Information To Be Released * 🛈

DUI ONLY - information that can be obtained/disclosed under this authorization includes the following: 🛈

Purpose of the Release Check all that apply *

Provide comprehensive care coordination

Determine eligibility for services

Request of the client/guardian

Other Other

Additional Information
Please note – The records released may contain alcohol and drug abuse information and/or information about Human Immunodeficiency Virus (HIV), Acquired Immunodeficiency Syndrome (AIDS), and AIDS Related Complex (ARC).

Alcohol/Drug Abuse *

I authorize the release of information relating to referral and/or treatment for alcohol and drug abuse

I PROHIBIT the release of information relating to referral and/or treatment for alcohol and drug abuse

HIV/AIDS/Sexually Transmitted Disease/Communicable Disease *

I authorize the release of information relating to HIV/AIDS/sexually transmitted disease/communicable disease

I PROHIBIT the release of information relating to HIV/AIDS/sexually transmitted disease/communicable disease

I understand that:
Information disclosed based on this Authorization, except for information about a substance use disorder, may be re-disclosed by the recipient and no longer be protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) (45 CFR part 164). Records about a substance use disorder will continue to be protected under federal rules following disclosure and cannot be disclosed or re-disclosed without my written consent unless otherwise provided for in the relevant rules (42 CFR part 2).

I cannot be required to sign this Authorization as a condition of treatment, payment, enrollment, or eligibility for benefits. Diversus Health may not refuse to treat me if I refuse this Authorization unless this Authorization is necessary for my participation in a research study, or the purpose of the treatment is to provide information to the individual/entity identified in this Authorization.

Substance Use Disorder-related information can be released in the event of a bonafide medical emergency without consent.
Under 42 CFR Part 2, I have the right to request a list of disclosures to which disclosures have been made pursuant to the general designation - For 42 CFR Part 2 violations, I can contact the US Attorney for Colorado at 1801 California Street, Suite 1600, Denver, CO 80202, 1-303-454-0100

Diversus Health has no control over this information after it is released and is not liable for any other disclosures.

I may revoke (cancel) this authorization at any time by notifying Diversus Health Medical Records in writing or by signing the revocation form. If not revoked, this Authorization will expire two (2) years from the date I sign it unless a date is specified below

This authorization is not for the disclosure of psychotherapy notes, as Diversus Health does not maintain psychotherapy notes as part of the medical records.

My signature below means I understand and accept the terms of this Authorization. A copy of this Authorization (including fax) is as valid as the original. I have a right to receive a copy of the signed Authorization.

Effective Date * +

Expiration Date +

Phone Number of person completing the form
(Client, Legal Guardian or Representative) *

Signature of Client, Legal Guardian or Representative *

clear

Print Name of person completing the form
(Client, Legal Guardian or Representative) *

If client is over 12 years old, client must sign

clear

Upload Photo ID of the person signing
Client, Legal Guardian or Representative

Assessments/Evaluations	Person Centered Plans/Treatment Plans
Progress Note	Psychological Test/Reports
Psychiatric Evaluations/Medication Reviews/Labs/Radiology	Treatment/Service Recommendations
Educational/Developmental	Discharge/Transfer Recommendations
Information Related to Benefits or Insurance	Work Related Information
Other Other

Enrollment	Attendance, hours and weeks completed	Education/treatment levels
Compliance and ancillary services	Cooperation	Treatment status and progress
Fee payment	Discharge status