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7. SIGNATURE AND DATE The client or legal representative must sign and date this authorization.
• This authorization may be revoked at any time by providing a written notice of revocation to the Release of Information (ROI) dept. at
1300 E. Bradford Parkway, Springfield, MO 65804, except to the extent that the agency has already taken action in reliance on it.
• I understand the information to be released includes behavioral and/or mental health care records and could include records related to
HIV/AIDS, communicable diseases and/or treatment for alcohol or substance use disorder.
• Information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be
protected by the Federal Privacy Law.
• Treatment, payment, enrollment or eligibility for benefits may not be conditioned on whether or not I sign this authorization.
• I may request a copy of the signed authorization.
• I may be charged for copies in accordance with state law.
• I have a right to inspect and receive a copy of the material to be disclosed.
• Federal law /42 CFR Part 2 prohibits unauthorized disclosure of these records.
Note: A client (18 years or older) must authorize the release of their own information unless incapacitated or deceased. If signing for a
minor client, I hereby state that my parental rights have not been revoked by a court of law. Specific situation(s) may require minor’s
authorization.
Signature (required) Date (required)
(mm-dd-yyyy)
Printed Name of Person Signing (if not client)
(First, Middle, Last)
Relationship to Client
Client Name (First, Middle, Last)
Date of birth (mm-dd-yyyy)
Medical Record Number
Biological/Adoptive Parent Legal Guardian
Legal Authorized Representative
Burrell Behavioral Health - Release of Information Department
1300 E. Bradford Parkway Springfield, MO 65804 | Phone: (417) 761-5270 | FAX: (229) 516-8290| ROI@burrellcenter.com
NOTE: If signed by a patient's authorized representative, supporting legal documentation must accompany this authorization form.
Authorization to Release Protected Health Information
INSTRUCTIONS: When picking up copies in person, a photo ID will be required as well as a copy of any legal documentation verifying
legal right to request such information.
1. Section 1: Type or write client name, date of birth and address. Check box if client is deceased.
2. Section 2: Indicate the reason information is being requested. For client access to your own records, check personal.
3. Section 3: Indicate who you are requesting information FROM.
4. Section 4: Indicate who you want the information released TO. If the client is a minor, list Legal Guardian's name and address.
5. Expiration date: Provide an expiration date. If no date is provided the authorization will expire 1 (one) year from the date it is signed.
6. Section 5: Indicate how you want to receive the information.
7. Section 6:
a. Enter the date range of records you are requesting. If you do not know the exact dates the month and year will be accepted.
(Example: May 2002 - September 2003). If you wish to release a series of visits extending into the future, you may enter the
option of "past, present, and future."
b. Enter the type of records requested. You may limit the amount of information provided by only checking the corresponding
boxes of the information needed. Substance Use Disorder records require special protections and are listed separately.
8. Section 7: Read disclosures, sign and date authorization. If signed by someone other than the client, include legal documentation, print
full name and indicate relationship to client.
9. Please contact the ROI department at the address or phone number listed below if you have questions or concerns. Due to the high
volume of phone calls, please allow 1-2 business days for a response. We appreciate your patience and look forward to serving you.
