Health Psych Maine, LLC 2 Big Sky Ln, Waterville, ME 04901 Release Form Patient Name(*) Invalid Input Date of Birth Month010203040506070809101112 / Day01020304050607080910111213141516171819202122232425262728293031 / Year19241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024 Invalid Input By initialing below, I authorize Health Psych Maine and my clinician, to: Invalid Input Give, Get, and Discuss Records and Information -- 2-way communication -- with (individuals/agencies below): Names of individuals or agencies you wish to allow communication with: Name(*) Invalid Input Address/Phone(*) Invalid Input Name Invalid Input Address/Phone Invalid Input Name Invalid Input Address/Phone Invalid Input Type of information to be disclosed: Psychological evaluation, Progress Notes, Treatment Plan Invalid Input Other Information Invalid Input This information may be released for the following reasons: Assist with Evaluation/Assessment, Coordination of Services, Treatment Planning, Judicial Proceedings Invalid Input Other Reasons Invalid Input This authorization shall remain in effect until for 2 years from the date of signing unless otherwise noted. I also authorize Health Psych Maine to communicate with my insurance company enough to facilitate authorization and payment. By signing below, you are authorizing the insurance company to pay benefits to Health Psych Maine. When we bill the insurance company, payment for services is thereby directed to us; if the insurance company accidentally sends the check to you, it is your responsibility to turn the check over to us. You have the right to revoke this authorization, in writing, at any time by sending such written notification to the office address. However, your revocation will not be effective to the extent that I have taken action in reliance on the authorization. You should be aware that your revocation may be the basis for denial of health benefits or other insurance coverage or benefits. I understand that in general my clinician may not make psychological services contingent upon my signing an authorization, unless the psychological services are provided to me for the purpose of creating health information for a third party. My clinician may decline to offer treatment for clinical reasons, e.g., if he/she feels that the treatment offered might not be a good fit for me at this time. There are some exceptions to confidentiality which are explained further in the Outpatient Therapy Agreement. Briefly, these exceptions include issues of child abuse, abuse of incapacitated adults, litigation, workers' compensation (WC), and pursuit of disability. I understand that if I am potentially suicidal or homicidal, my clinician may contact others, including significant others, only as necessary to prevent harm. For quality assurance reasons, the clinicians at Health Psych Maine sometimes obtain consultation with and discuss cases with each other in the interest of providing the best possible care. This is usually done in de-identified format, but cannot always be done that way. Other professionals and staff in the practice are legally bound to protect your confidentiality. I understand that I may refuse authorization to disclose all or some healthcare information but that refusal may result in improper diagnosis or treatment, denial of coverage or a claim for health benefits or other insurance, or other adverse consequences. I understand that if this authorization is in electronic form, a unique identifier of me (i.e. a Social Security Number) and the date I authenticated the electronic authorization must be included on the authorization form. I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient of your information and no longer protected by the HIPAA Privacy Rule. I understand that I have the right to: Inspect or copy the protected health information to be used or disclosed as permitted under Federal Law (or state law to the extent that the state law provides better access rights); and refuse to sign this authorization. I may have a copy of this form upon request. Client Signature(*) Invalid Input Date Invalid Input If the authorization is signed by a personal representative of the patient, a description of such representative’s authority to act for the patient must be provided. State and Federal laws require my specific consent to disclose information pertaining to HIV testing or treatment, mental health treatment, and/or substance abuse treatment information. I understand that I may request to review any information in my medical record and may refuse to disclose some or all of my records. However, such refusal may result in improper diagnosis or treatment, denial of insurance benefits, or other adverse effects. I understand that my records may contain information pertaining to HIV testing or treatment, mental health treatment, and/or substance treatment, and I agree to the release of this information by signing below: Signature(*) Invalid Input Date Invalid Input To the Receiving Provider: This information has been disclosed to you from records protected by Federal confidentiality rules (42CFR part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by written consent of the person to whom it pertains or as otherwise permitted by 42CFR part2. A general authorization for the release of medical information or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. Release form.docx Submit
