LABEL AREA
Innovations Ft. Worth
Consent to Release MH & SUD Records
Consent to Release MH & SUD Records IP-MS2P-067-13
Updated 06/09/21
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Patient Information
Patient Name: Date of Birth:
/ /
Phone:
( )
Address/City/State/Zip: Dates of Treatment:
From: To:
Program(s) to Release:
9 IP 9 IOP 9 PHP 9 Med Mgmt 9 Assessment Only
Release Information to (recipient):
Address:
Attn:
Attn:
Phone: Phone: Fax:
Fax:
Email:
How would you like to receive your information: Mail Pick-up Fax Encrypted Email (Provide recipient address/fax/email above)
The Purpose Of Release:
Continuum of Care (CoC): Is this consent approved for the exchange of records between this facility & the recipient above? Yes No
Disability Financial Legal/Court Insurance Other Please specify:
Information to be RELEASED I understand the information to be released or disclosed may include information relating to sexually transmitted
diseases, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV), and alcohol and drug abuse. I authorize the release
or disclosure of this type of information. Please select information to be released by selecting Yes/No:
Include Substance Use History/Treatment?
Yes No Drug/Alcohol Test Results? Yes No
Discharge Order? Yes No Discharge Summary? Yes No Discharge Plan? Yes No Medications? Yes No
Psychiatric Eval (CPE)? Yes No History and Physical? Yes No Labs? Yes No Billing? Yes No
MD/NP Progress Notes? Yes No Treatment Plan? Yes No Other:
• Upon presentation to complete a request or pick up records, identification will requested to ensure validity/authority of the receiving party.
In compliance with the HIPAA Privacy Rule regarding the release of mental health information and the federal confidentiality rules regarding the
release of substance use disorder treatment information (42 CFR Part 2), I acknowledge the following:
(1) This consent is subject to revocation at any time, except to the extent that the facility has taken action in reliance on the patient’s prior consent.
Revocation for mental health records must be provided in writing; revocation of substance use disorder records may be in writing or given
verbally.
(2) If not previously revoked, the patient’s consent to release mental health and/or substance abuse information will expire 90 days after the date
of this release unless otherwise noted here:
(3) This authorization is in effect until the expiration date, event or condition is met and regardless of whether the patient is still receiving services
from the provider.
(4) If requested, the patient is entitled to an accounting of the disclosures of their protected health information.
(5) I understand that my treatment, payment, enrollment, eligibility for benefits will not be conditioned on whether I sign this authorization.
(6) I understand that the PHI used or disclosed pursuant to this authorization may be subject to re-disclosure by the person(s) receiving it and no longer
protected by the federal Privacy Rules.
___/___/___ ____:____AM/PM
Patient/Legal Representative Signature Printed Name / Relationship (if other than patient) Date Time
(If POA or Legal representative, please provide copy of legal documents)
___/___/___ ____:____AM/PM
Witness Signature Printed Name Date Time
___/___/___ ____:____AM/PM
2nd Witness Signature (if verbal/telephone consent) Printed Name Date Time
Hospital Staff: Complete an Accounting of Disclosure each time you release records to outside entities. Record each release on form Record of Document of Disclosure (IP-W-066)
Verbal/Telephone Consent should be the exception in extenuating circumstances. Use of the Electronic form in Pulse should be used when feasible rather than verbal consent.
Verbal/Telephone Consent is NOT PERMITTED for patients treated for Substance Use; it is not allowed under 42 CFR part 2 Regulations, authorization must be written/e-signature.
NOTE TO RECEIVER This information has been disclosed to you from information protected by Federal confidentiality rules (42 CFR part 2). The Federal rules prohibit you from making any further disclosure of information in this record
that identifies a patient as having or having had a substance use disorder either directly, by reference to publicly available information, or through verification of such identification by another person unless further disclosure is expressly
permitted by the written consent of the individual whose information is being disclosed or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose
(see §2.31). The Federal rules restrict any use of the information to investigate or prosecute with regard to a crime any patient with a substance use disorder, except as provided at §§2.12(c)(5) and 2.65.
Release Information from (facility):
Innovations Ft. Worth
6421 Camp Bowie Boulevard, Suite 200
Ft. Worth, TX 76116
817-841-8002
817-377-0441
