Commonwealth of Massachusetts Department of Mental Health (DMH)
REQUEST FOR DMH SERVICES – Service Authorization Use Only
Authorization for Release of Information
Two Way
SA v. 2018 07
Page 2 of 2
Patient/Applicant Name: ______________________________________
5. Please check to indicate you give permission to release the following information if
present in your record: (check all that apply)
HIV test results (Authorization required for each release request.)
Alcohol and Drug Abuse Records Protected by Federal Confidentiality Rules 42 CFR Part
2 Federal rules prohibit any further disclosure of this information unless disclosure is
expressly permitted by written authorization of the person to whom it pertains or as
otherwise permitted by 42 CFR Part 2.
Purpose of the Release: Service authorization.
I understand that:
• I have a right to revoke this authorization at any time.
• If I revoke this authorization, I must do so in writing and present it to DMH at the DMH
address identified on page one or the DMH office in my area. (Find DMH area offices at
www.mass.gov/dmh-offices-facilities-and-staff-directory; call 1-800-221-0053; or email
dmhinfo@MassMail.State.MA.US.)
• The revocation will not apply to information that has already been released pursuant to this
authorization.
• The revocation will not apply to my insurance company when the law provides my insurer
with the right to contest a claim under my policy.
• Once the above information is released, the recipient may redisclose it and the information
may not be protected by federal or state privacy laws or regulations.
• Authorizing the disclosure of the information identified above is voluntary.
• I need not sign this form to receive treatment or services from DMH and/or the other named
person, facility or agency; however, lack of ability to share or obtain information may prevent
DMH, and/or the other named person, facility or agency, from providing appropriate and
necessary care.
This authorization will expire (specify a date, time period or an event) __________________or,
if nothing is specified, it will expire the later of: (i) one year from date of signing; or (ii) if
applicable, when I am no longer receiving services from DMH.
6. Signature / Authorization: Sign and provide information as required below.
X _____________________________________________ __________________
Your signature or Personal Representative’s signature Date
_____________________________________________________
Print name of signer
The following information is needed if signed by a personal representative:
Type of authority (e.g., court appointed, custodial parent): _____________________________
If court appointed provide copy of court order.
