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Authorization For Release of Information Form

This document is an authorization form for releasing personal health information. It allows the individual to select which Maine Department of Health and Human Services (DHHS) offices can share their information and with whom. The individual provides their name and contact details. They then choose whether DHHS offices can release information to or obtain information from other organizations. The purpose, specific information, and how it will be shared (e.g. email) is indicated. By signing, the individual consents to DHHS sharing their information as outlined for up to one year.

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3K views

Authorization For Release of Information Form

This document is an authorization form for releasing personal health information. It allows the individual to select which Maine Department of Health and Human Services (DHHS) offices can share their information and with whom. The individual provides their name and contact details. They then choose whether DHHS offices can release information to or obtain information from other organizations. The purpose, specific information, and how it will be shared (e.g. email) is indicated. By signing, the individual consents to DHHS sharing their information as outlined for up to one year.

Uploaded by

WGME
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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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  Other:
 Division of Licensing and Certification  Other:

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 Organization

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
Other:

To share the information with others by EMAIL, please initial and complete the following.

I understand that email and the internet have risks that the office sharing my information cannot control. It is possible
that my emailed information could be read by a third party. I ACCEPT THOSE RISKS and still ask to send my
information by email. INITIAL HERE ______
Please print the email address where you want your information sent:

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DHHS authorization 2020
What information should be released or obtained? Please check all that apply.

General permission: Special permission: Drug/Alcohol Treatment or Referral


for Services
 All health information from the office(s) checked
above  Include all drug/alcohol information in the release
 Claims or encounter data (information about visits  Include only the specific drug/alcohol records checked:
to health care providers)
 Billing, payment, income, banking, tax, asset, or data  Diagnosis and treatment
needed to see if you qualify for DHHS program  Clinical notes and discharge summaries
benefits  Drug/Alcohol history or summary
 Limit to the following date(s) or type(s) of information:  Payment or claims information
(for example “Lab test dated June 2, 2019” or “Claims  Living situation and social supports
from 2018-2020”)  Medication, dosages or supplies
 Other: ____________________________________  Lab results
 Other:
Special permission: Mental/Behavioral Health Services Special permission: HIV/AIDS Status/Test Results

 Include this information in the release  Include this information in the release

 I want to review my mental health/behavioral health Please note: Maine law requires us to tell you of possible
record before release. I understand that the review will effects of releasing HIV/AIDS information. For example,
be supervised. you may receive more complete care if you release this
information, but you could experience discrimination if it is
Please note: Maine law allows us to share this information misused. Your HIV/AIDS-related information, and all of
with other health care providers and health plans to your data, will be protected as the law requires.
coordinate and manage your care (to help take care of you)
so long as we make a reasonable effort to notify you of the
release.

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
http://www.maine.gov/dhhs/privacy/index.shtml 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:


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DHHS authorization 2020

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