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DHHS authorization 2020
Authorization to Release Information
We are committed to the privacy of your information.
Please read this form carefully.
Which office(s) should help you? Please check.
Office of MaineCare Services
Office of Behavioral Health
Office for Family Independence and Medical Review Team
Office of Child and Family Services
Maine Center for Disease Control and Prevention
Office of Aging and Disability Services
Dorothea Dix Psychiatric Center
Office of Administrative Hearings
Riverview Psychiatric Center
Division of Licensing and Certification
Whose information will be disclosed? Please print clearly.
Individual’s Name
Date of Birth
Home Address Town/City State Zip Code
Telephone Email address of individual/personal representative (optional)
Please check: Release/Send my information to: Obtain/Get my information from:
Name of Individual
Address Town/City State Zip Code
Telephone Email address (optional)
What is the purpose of the disclosure?
Personal request
To coordinate or manage my care
For a legal matter, including testimony
To see whether I qualify for insurance coverage, services, or benefits
To share the information with others by EMAIL, please initial and complete the following.
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DHHS authorization 2020
What information should be released or obtained? Please check all that apply.
General permission:
All health information from the office(s) checked
Claims or encounter data (information about visits
to health care providers)
Billing, payment, income, banking, tax, asset, or data
needed to see if you qualify for DHHS program
Limit to the following date(s) or type(s) of information:
(for example “Lab test dated June 2, 2019 or “Claims
from 2018-2020”)
Other: ____________________________________
Special permission: Drug/Alcohol Treatment or Referral
for Services
Include all drug/alcohol information in the release
Include only the specific drug/alcohol records checked:
Diagnosis and treatment
Clinical notes and discharge summaries
Drug/Alcohol history or summary
Payment or claims information
Living situation and social supports
Medication, dosages or supplies
Lab results
Special permission: Mental/Behavioral Health Services
Include this information in the release
I want to review my mental health/behavioral health
record before release. I understand that the review will
be supervised.
Please note: Maine law allows us to share this information
with other health care providers and health plans to
coordinate and manage your care (to help take care of you)
so long as we make a reasonable effort to notify you of the
Special permission: HIV/AIDS Status/Test Results
Include this information in the release
Please note: Maine law requires us to tell you of possible
effects of releasing HIV/AIDS information. For example,
you may receive more complete care if you release this
information, but you could experience discrimination if it is
misused. Your HIV/AIDS-related information, and all of
your data, will be protected as the law requires.
I understand and agree that:
I am signing this form voluntarily. I have the right to a signed copy of this form if I request one.
My treatment, payment for services, or benefits will not depend on whether I sign this form unless I am requesting or
disclosing information to apply for benefits.
“Information” may be in written, spoken and/or electronic format, and includes information about me from other
healthcare providers (such as doctors, hospitals, and counselors) that is included in my files. My signature allows the
people/offices named on the reverse to discuss my information for the purposes noted on this form.
My information will be kept confidential as required by law. If I choose to share my information with others who are
not required by law to keep it private, it may no longer be protected by federal confidentiality laws.
If alcohol or drug treatment or program (substance use disorder) records are included in this release, a notice will be
included with the records saying that such information may not be re-released or shared without my written permission.
I may revoke (take back) my permission to release my information by filling out the Revocation Form found at and sending it to the office that shared my information. The
Revocation Form is effective only after it is received and does not apply to information that was already shared.
If I take back my permission or refuse to release some or all of my information, my choice could lead to an improper
diagnosis or treatment, or denial of insurance.
This form expires one year from the date below unless I write an earlier date here: _____________________
This form permits additional releases until it expires.
Date: Signature:
Personal Representative’s authority to sign: