MERCED COUNTY BEHAVIORAL HEALTH & RECOVERY SERVICES AUTHORIZATION FOR RELEASE OF INFORMATION

Transcription

1 MERCED COUNTY BEHAVIORAL HEALTH & RECOVERY SERVICES AUTHORIZATION FOR RELEASE OF INFORMATION PATIENT INFORMATION (Complete as on-line form or print) i:;-irst Name: Last Name: Maiden Name / Aliases: b.o.b.: s oftreatment / services covered by this authorization: SSN: i)o(x-xx- (Last 4)!From: Telephone/Cell Phone # : rro: Explanation: This authorization conforms to the requirements of the State and Federal laws governing the release and receipt of protected patient health information (PHI). Refer to: HIPAA, 45 CFR Parts 160, 164, Subparts A & E; W & I Code 5328; 42 CFRPart 2 I, hereby authorize the following programs, agencies and individuals to disclose to and communicate with one another as necessary, for the purpose of coordinating my care, treatment, financial responsibility, maintenance of my records and for outcome analysis: (Please initial beside each checked box) rgj Merced County Behavioral Health and Recovery Services/Alcohol and Other Drug Programs Public Conservator/Guardian Central California Alliance for Health Mercy Medical Center Golden Valley Health Center Merced County District Attorney ~ Public Health Merced County Public Defender Family Care Merced County Probation Department Merced Faculty Associates Superior Court of California/Juvenile Court D Castle Family Health Centers Superior Court Presiding/Assigned Judge D Memorial Hospital Los Banos rgj Human Services Agency CalWORKS rgj Residential Facility 0 NTP (2$1 Parent/Guardian rgj Primary Care Physician IZl Psychiatrist Other Physician School Counselor [2Sl Teacher Teacher ~ Principal/Vice Principal 181 Other Person or Agency f8'j Other Person or Agency..::a:C;_:V""'R"""C=/Mc.a..:.:.=C=O=E=/. A... s4"-p... ir=an=e=t This information includes the following: rgj Assessment, ConsumerPlan ofcare, Treatment Plan, Progress Notes, Diagnosis, and Prognosis rgj Prevention / Education information rgj rgj Medical/physical health, Mental Health, and Substance abuse treatment history including plan, details of participation, past and current medical/mental/substance abuse condition Periodic reports to evaluate patient progress in treatment, including Court Reports Results and dates ofdrug tests Name: Chart # MH-668 Rev. 06/ 11 /13, 3/12/2014, 3/17/2014, 5/20/14, 0 1/12/2017

2 MERCED COUNTY BEHAVIORAL HEALTH & RECOVERY SERVICES AUTHORIZATION FOR RELEASE OF INFORMATION Results of psychological or vocational tests Current medications Medical diagnoses Health Status Prognosis Medical/psychosocial history Results ofmedical/laboratory tests Medical/physical health, Mental Health and Substance Abuse Rx/Pharmacy information HIV/AIDS Information Financial agreement/ Documents and payment information Attendance Reports Social and academic functioning Access to Cumulative Files IEP Reports Grade Reports Disciplinary Reports Other CPS Court Reports/Psychiatric Evaluations Other Your medical and mental health record may contain information that you or representatives provided to us, or authorized our agency to obtain, from other confidential sources. These authorizations may allow release ofinformation from third party providers. You may review that information to determine what, ifany, information you do not want released. Exceptions or information that I do not want released I disclosed: Not applicable (Initial if not applicable) --- I understand that such information cannot be released without my consent, except when required by law, and that all restrictions contained in this authorization as to the usage, transfer, or re-disclosure of such information apply to such records. I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so by signing below or by submitting my written revocation to the Merced County program of origin. I understand that the revocation will not apply to the information that has already been released in response to this authorization. I understand that authorizing the use or disclosure of the information identified above is voluntary. This document will aid and support communication between Merced County Behavioral Health & Recovery Services/AOD and other County services. It will also aid and support communication with medical services providers and individuals with whom you authorize exchange of information. Name: Chart# MH-668 Rev.06/11/13, 3/12/2014, 3/17/2014, 5/20/14, 01 / 12/2017

3 MERCED COUNTY BEHAVIORAL HEALTH & RECOVERY SERVICES AUTHORIZATION FOR RELEASE OF INFORMATION Ri~ht of Consumer to Receive a Copv of Authorization: I, (Initial) ---- Do.Do Not want a copy of this authorization. of Expiration or as specified: (initial) Mandated Criminal Justice Only: There has been a formal/continuous and effective termination or revocation of my release from confinement, probation or parole or other proceedings under which I was mandated into treatment. Prohibition of Usa~e. Transfer. or Re-disclosure oflnformation: Except as required by State or Federal laws, the use of information released for purposes other than the stated purpose or redisclosure or transfer of this information to any person or entity not named herein is prohibited. An additional written authorization must be obtained for any proposed new use of the information or its re-disclosure or transfer of such information. Authorized information may be subject to re-disclosure by the recipient and no longer protected by the privacy regulations. Signature ofpatient I consumer, and/or legal representative If signed by legal representative, authority/relationship to patient: I verify that: patient's/consumer's identity was confirmed, and the contents of this document were reviewed and discussed with Patient/Consumer. Witness Minors: By federal regulations ( 42 C.F.R. Part 2), drug/alcohol abuse or HIV/AIDS related information given by a minor, his/her parent, guardian or other person authorized to act on his/her behalf, the minor's signature is also required along with that of the parent, guardian or other authorized person (unless minor adjudicated incompetent). Where State law allows a minor to consent to treatment, only the minor is required to sign. Consent to Release Information Revoked: Signature : Verbal notification of revocation of consent to release information Staff Initial Name: Chart#: MH-668 Rev. 06/11/13, 3/12/2014, 3/17/2014, 5/20/14, 01/12/2017

4 ' ME4CEDh- C OUNTY BEHAVIORAL HEAL TH AND RECOVERY SERVICES Servicios de Behavioral Health and Recovery Del Condado de Merced AUTHORIZATION FOR TREATMENT OF A MINOR Autorizaci6n para tratamiento de un menor I, the undersigned, hereby request admission of Yo, el subscrito, por este medio solicito (BHRS), Merced, California, to Merced County Behavioral Health and Recovery Services /os Servicios de Behavioral Health and Recovery de/ Condado de Merced (BHRS), California, and consent to (his/her) care and treatment as is prescribed by (his/her) attending physician or y doy permiso para el cuidado y tratamiento como esta prescrito por su medico 6 his/her associates. sus asociados. Unless revoked, this release will expire one year from this date. Si no anulo este permiso, se vencera a partir de un aflo despues de esta fecha. /Fecha Signature of Parent or Guardian Signature of Parent or Guardian Firm a de la Madre 6 guardian Witness Testigo EMANCIPATED MINOR INFORMATION FORM Forma de un Menor Emancipado For the purposes of obtaining diagnosis or treatment at BHRS, Con el prop6sito de diagnosticar 6 tratamiento en el BHRS, the undersigned certifies that the following facts to be true: el subscrito certifica que los datos son verdaderos: 1. I am living separate and apart from my parents or legal guardian. Vivo aparte de mis padres 6 guardian. 2. I am managing my own financial affairs regardless of source of income. Manejo mis propias finanzas de doquiera que sea el origen de mis ingresos. 3. I am ---~ears of age, having been born on the day of, 20 Tengo anos de edad, haber nacido en el dia de Unless revoked this release will expire one year from this date. Si no anulo este permiso, se vencera a partir de un ano despues de esta fecha. Signed (Firma) /Fecha Witness (Testigo) Authorization for Treatment of Minor Eng.Span MH /2010

5 1 MEfiCEDA COUNTY Acknowledgement of Receipt of Notice of Privacy Practices I, --~ hereby acknowledge receipt of the Pat1ent/ChenVConservator/Parent or Legal Guardian Notice ofprivacy Practices from Merced County Behavioral Health and Recovery Services (BHRS). I have read and understand this information: Signed: : Indicate relationship (if not signed by patient/client) and the authority to represent the patient/client: ************************************************************************************ Patient/client did receive the Notice of Privacy Practices but did not sign this acknowledgement of receipt ofsaid Notice because: _. Patient/client left office before Acknowledgement could be signed. Patient/client does not wish to sign this form. Patient/client cannot sign this form ( explain:, Patient/client did not receive the Notice of Privacy Practices because: Patient/client required emergency treatment. Patient/client declined receipt ofnotice of Privacy Practices and does not wish to sign this form. Other (Explain : ~ Signed: : BHRS Representative Acknowledgement of Receipt of Notice of Privacy Practices MH490 Version

6 '!\ 114E B.:CEC,~ Behavioral Health and Recovery services C::C, LI IV T Y Assignment of Benefits The Merced County Behavioral Health and Recovery Services (BHRS) is responsible to see that fees are charged for services and that they are collected from all sources (Welfare and Institutions Code, sections 5709 and 5718). I authorize BHRS to receive payment of benefits from any and all health insurance plans under which I am covered. I understand that I am financially responsible for my personal liability not covered by insurance. The above information is true and correct to the best of my knowledge. I hereby authorize Merced County and its duly authorized representatives, that upon default of any and all accounts that are past due more than 30 days, to access my financial records through any major Credit Reporting Agency for collection purposes only. The undersigned certifies that he/she has read the foregoing and is authorized to sign. Signature of Patient or Authorized Person Print Witness Name Signature of Witness BHRS follows the California Department of Health Care Services' method of Determining Ability to Pay for Community Mental Health Services. State law requires that your charges be based upon your ability to pay. Your financial situation determines your ability to pay for your personal liability. You are obligated to pay either the full cost of care or your personal liability of $, for all services received during the 12 month period commencing on your first date of service (_/ / to / / J. As long as your financial situation remains the same, you will never be obligated to pay more than your annual personal liability, even if the cost of your care is higher. Your insurance carrier, however, may be billed for the full cost of services. Please contact us as soon as possible if: 1. You are unable to make payments. 2. Your income changes either up or down. 3. The number of people dependent on your income changes. 4. There is a change in your assets. You may call the Fiscal Services Office at (209) , if you have any questions regarding your bill. Signature of Patient or Authorized Person Print Witness Name Signature of Witness For Staff Use Only Print Consumer Name Consumer Chart Number MH-,80 02/201c;