Authorization for release and disclosure, and/or request for medical information and records – MICHIGAN

Please note that you may be contacted by the Health Information Management (HIM) Department to verify or clarify information in this online release of information.

Do you want medical information and records sent or received?

Yes

Patient Name*

First Last

Patient Date of Birth*

Patient Phone #*

This patient contact phone number will be used in the event we have questions about this release or a records request.

Patient Address*

This patient contact address will be used in the event we have questions about this release or a records request and we can't reach you by phone or if you request that a copy of this release be mailed to you.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Form Completed By*

If Other, please describe relationship to patient*

Name of person completing the release, if not the patient*

First Last

I authorize Pine Rest Christian Mental Health Services to:*

(must choose one or both from the list below)

release information from my medical records to the individual/organization listed below

request information from the individual/organization listed below

Name of the Individual/Organization*

Phone*

Phone number for the Individual/Organization

Fax

Fax number for the Individual/Organization

Address*

Address for the Individual/Organization

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

For the following purpose, use, or need:*

Insurance

Coordination of Care

Legal

Personal Use

School/Education

Military

Disability

Employment

Other

Check all that apply

Explain:

The following information from my psychiatric/medical records may be disclosed, covering the dates indicated below:

Treatment start date*

Can use birth date if exact start date is unknown.

Treatment end date*

Examples: 12/31/2020, case closure, 60 days after case closure, etc.

Information for disclosure:

Check all that apply

Treatment Summary

Psychiatric Evaluation

Psychological Testing

Physical Exam

Laboratory Studies

Initial Assessment

Exchange of all written and verbal health information pertinent to the coordination of my care and treatment

Other

Exclude the following information:

Other:*

Description of information to be excluded:*

I acknowledge such information cannot be disclosed without my written informed consent unless otherwise provided by law. I further understand that such information to be disclosed may include treatment of Psychiatric, Substance Abuse, and HIV/AIDS related illnesses. I agree that the information may be faxed for expediency. I have the right to revoke this authorization at any time. Any revocation will be done in writing to the attention of the Medical Records Director and any information previously authorized and released will not be subject to revocation. I acknowledge and authorize that the information indicated on this form will be sent to the individual listed above. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) protects the privacy of health information. Persons or organizations receiving this health information may not be bound by the provisions of this law. However, re-disclosure of this information is prohibited by the Michigan Mental Health Code (sections 748, 749 and 750 of the Public Act 258 of 1974 as amended) and also by Title 42 of the Code of Federal Regulations, Part II, with which this authorization complies. The released information may not be copied, shared or re- released, except as consistent with the authorized purpose stated above. I understand that I am not required to sign this authorization, and that Pine Rest will not refuse me treatment if I refuse to sign. I have the right to inspect and obtain a copy of the information disclosed. A true and exact photocopy/faxed copy of this authorization shall have the same effect as the original.

Intent of Release*

Please select one or both, as applicable.

I am requesting records be sent to the above named person/organization within the next 30 days

I am to have this form on file and it may be used to communicate with or send records to the above named person/organization if needed prior to the expiration date

If no expressed revocation is issued, this authorization will expire one year from the date indicated after my electronic signature or upon the following date, event or condition:

I would like someone to explain this form to me.*

Yes

I would like a copy of this release form mailed to me.

Yes

This document was completed and submitted by the patient/parent/legal guardian and constitutes an electronic signature for this release of information.*

Submitting this form for someone other than yourself or legally guarded person is considered fraudulent and will not be accepted.

First Last

Signature Date*

Authorization for release and disclosure, and/or request for medical information and records – MICHIGAN

Release Of Information

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