BHWC ROI ANTHC Behavioral Health Wellness Clinic Authorization for Use and Disclosure of Health Information Form. Authorization For Use and Disclosure of Health Information Step 1 of 6 – Client Information 16% CLIENT INFORMATIONClient First Name(Required)Client Last Name(Required)Client Date of birth(Required) Month Day Year Client Phone(Required)Email Client Address Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code TYPE OF INFORMATION TO BE RELEASED / REQUESTEDI authorize disclosure / verbal discussion of the following (check appropriate boxes):(Required) Complete BHWC behavioral health record Behavioral Health Assessments Individual Counseling Progress Notes Group Counseling Progress Notes Case Management Notes Only BHWC behavioral health information for the following dates (Specify) Other (Specify) Authorization from(Required) Month Day Year Authorization to(Required) Month Day Year Other (Specify)(Required) DISCLOSURES TO RECIPIENTSName of Recipient (Provider/Agency Name):(Required)Recipient Phone Number(Required)Email Address FaxHow would you like us to release the records?Select email or fax…EmailFaxMailing Address Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code PURPOSE OF DISCLOSUREPurpose of Disclosure:(Required) Personal Use Legal Coordination of Care State/Federal Insurance/Benefits Other (Specify) Other (Specify)(Required) LENGTH OF AUTHORIZATIONExpiration: This authorization will expire one (1) year from the signature date. If alternative expiration date is desired, provide date below.Alternative expiration date: Month Day Year Revocation: An authorization may be revoked at any time by written notice to BHWC. Revocation is not effective until notice is received and is not effective regarding disclosures made before revocation and where authorization was obtained as a condition of insurance coverage. PATIENT RIGHTSI understand that: (1) I have a right to receive a copy of this signed authorization upon request; (2) I have a right to refuse sign this authorization – BHWC may not condition treatment, payment, enrollment in a health plan or eligibility for health care benefits on a decision to sign this form; and (3) I have a right to inspect or copy my health information. I may arrange to inspect or copy information maintained by BHWC by contacting BHWC. I may be charged a reasonable fee for copying costs.REQUESTORI authorize the disclosure of health information described above. Information released under this authorization may be subject to re-disclosure by the recipient and may no longer be protected by Federal privacy standards, including HIPAA and the Privacy Act of 1974. A photo copy/fax of this form is as valid as the original.SIGNATUREI have been given time to read, understand, and ask questions about this form.Name of ClientToday's Date(Required) Month Day Year PhoneThis field is for validation purposes and should be left unchanged.
