Form Repeater Test Step 1 of 6 – Client, or my personal representative Information 16% I, Client, or my personal representative (parent or legal guardian) hereby authorize the Behavioral Health Wellness Clinic (BHWC) to use and disclose health information and substance use disorder treatment information with my treating health care providers. The information may be used/disclosed for the treatment, payment and health care operations and other permissible purposes under applicable law and regulations. The health providers rendering treatment may also use these information as necessary for its own treatment, payment or health care operations activities such as care coordination.Client First Name(Required) Middle Name Client Last Name(Required) Client Date of birth(Required) Month Day Year Client Phone(Required)Email Client Address Street Address Address Line 2 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 RECIPIENTSI, Client, or my personal representative (parent or legal guardian) hereby authorize Behavioral Health Wellness Clinic (BHWC) to release health information and substance use disorder treatment information to the following (person or entity):Person or entity to release health information to: Who would you like your ANTHC Behavioral Health Wellness Clinic health information sent? The name of the person or the organization you would like us to send your records to.Recipient or Entity PhoneRecipient or Entity Mailing Address Street Address Address Line 2 City 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 State ZIP Code Recipient or Entity FaxRecipient or Entity Email Add RecipientRemove RecipientDISCLOSURES TO RECIPIENTSI, Client, or my personal representative (parent or legal guardian) hereby authorize Behavioral Health Wellness Clinic (BHWC) to release health information and substance use disorder treatment information to the following (person or entity):If you are having any difficulties with this form, please call us at 1 (833) 642-BHWC (2492) or (907) 729-BHWC (2492) for assistance. TYPE OF INFORMATION TO BE RELEASED / REQUESTEDI authorize disclosure / discussion of the following (check all appropriate boxes):(Required) All my BHWC behavioral health record information and substance use disorder information Only BHWC behavioral health information Only BHWC substance use disorder information Substance Use Assessments (Psychiatric Diagnostic Evaluation) Behavioral Health Assessments and Individual Counseling Progress Notes Letter of Confirmation of Care Case Management Notes Other (Specify) Other(Required) If you are having any difficulties with this form, please call us at 1 (833) 642-BHWC (2492) or (907) 729-BHWC (2492) for assistance. Purpose of DisclosureWhy are you requesting this release of information?(Required)Please be as specific as possible and the purpose behind requesting this release of information. LENGTH OF AUTHORIZATIONUnless revoked, this authorization is limited to the following time period, which must be no longer than reasonably necessary to serve the purpose of the disclosure: Beginning date of authorization(Required) MM slash DD slash YYYY End date of authorization(Required) MM slash DD slash YYYY If you are having any difficulties with this form, please call us at 1 (833) 642-BHWC (2492) or (907) 729-BHWC (2492) for assistance. APPLICABLE LAWBy signing this authorization form, I understand and agree that: My protected health information and substance use disorder treatment information is protected under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and federal regulations governing the confidentiality of substance use disorder patient records, 42 CFR Part 2. Recipients of my information pursuant to this authorization may not further disclose my substance use disorder information without my consent, unless permitted under HIPAA; 42 USC § 290dd-242; and 42 CFR Part 2. Recipients will be notified of this obligation in the Prohibition on Re-Disclosure which must accompany all disclosures of my substance use disorder information. 42 CFR § 2.32. I may revoke this authorization in writing at any time by notifying BHWC, except to the extent that BHWC has already used or disclosed information in reliance on my authorization. I will not be denied services if I consent to disclosure, unless disclosure is necessary for BHWC’s proper treatment of me, obtaining payment for my services, or its health care operations. I have been given time to read, understand, and ask questions about this form. Please upload a picture of your photo ID Drop files here or Select files Accepted file types: jpg, jpeg, pdf, png, Max. file size: 8 MB. SIGNATURESigned Date Patient name(Required) Please type patient name here.
