Authorization for Release of Medical Records/Information

Patient Name:

Patient Date of Birth:

Patient Address:

Patient Phone:

The following individual or organization is authorized

Organization: Concordia Mind Health

Choose one:

Disclose information

Receive information

Address: 5000 S. Minnesota Ave. Ste 201 Sioux Falls, SD 57108

Phone: 605-400-9975

Fax: 605-271-6166

The following individual or organization is authorized

Disclose information

Receive information

Organization / Name:

Address

City

State/Province

Zip/Postal

Phone:

Fax:

Information to be disclosed:

Entire record (charges may apply)

Standard chart copy (includes demographics, provider reports, test results, etc.)

Other

Substance Abuse Documentation:

Check this ONLY if you permit substance abuse records to be released. These released records contain substance abuse documentation, and therefore prohibition on redisclosure applies. This information is released subject to the confidentiality provision of federal statutes (42 U.S.C. 290dd-2, and regulations 42 CFR, Part 2) which prohibits any further disclosure of this information without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations.

Service Dates

Dates of Service:

(date) to (date)

Information to be disclosed in the following format:

Fax

Mailed to provider

Purpose of Disclosure:

Continued healthcare

Medical/Billing/Payment

This authorization will expire on (insert date below), and unless revoked by the undersigned, shall remain in effect for one year from the date of signing this authorization.

I, the undersigned, do acknowledge as follows:

I understand that I have the right to revoke this authorization at any time, and may do so in writing. I understand that revocation will not apply to: 1. Information already released in response to this authorization. 2. My insurance company when the law provides my insurer with the right to contest a claim under my policy.

I understand that the information released may include sensitive information, including, but not limited to behavioral or mental health services or treatment records.

I am signing this authorization of my own free will. I understand that I can refuse to sign this authorization and still receive treatment.

I understand that I may review the information to be disclosed, as provided in 45 CFR 164.524.

I understand any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by federal confidentiality rules.

Patient Signature:

Clear

Printed Name of Patient:

If signed by Legal Representative, Relationship to Patient:

If you are human, leave this field blank.

Start Over