By initialing below, I authorize Health Psych Maine and my clinician, to:
Give, Get, and Discuss Records and Information -- 2-way communication -- with (individuals/agencies below):
Names of individuals or agencies you wish to allow communication with:
Type of information to be disclosed:
This information may be released for the following reasons:
If the authorization is signed by a personal representative of the patient, a description of such representative’s authority to act for the patient must be provided.
State and Federal laws require my specific consent to disclose information pertaining to HIV testing or treatment, mental health treatment, and/or substance abuse treatment information. I understand that I may request to review any information in my medical record and may refuse to disclose some or all of my records. However, such refusal may result in improper diagnosis or treatment, denial of insurance benefits, or other adverse effects. I understand that my records may contain information pertaining to HIV testing or treatment, mental health treatment, and/or substance treatment, and I agree to the release of this information by signing below:
To the Receiving Provider: This information has been disclosed to you from records protected by Federal confidentiality rules (42CFR part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by written consent of the person to whom it pertains or as otherwise permitted by 42CFR part2. A general authorization for the release of medical information or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.