BROWN COUNTY HUMAN SERVICES/MENTAL HEALTH CENTER



BROWN COUNTY HEALTH & HUMAN SERVICES

AUTHORIZATION FOR USE/DISCLOSURE OF PROTECTED HEALTH INFORMATION

|Client’s Name: | |#: | |D.O.B.: | |

|I AUTHORIZE: | |Treatment Alternatives & Diversion |

|Brown County Health & Human Services | | |

|300 E. Walnut | |Phone: (920) 391-48466 Fax: (920) 391-4888 |

|Green Bay, WI 54301 | | |

|TO EXCHANGE WITH WHOM: | | CHECK HERE IF AUTHORIZATION IS DISCLOSURE ONLY |

| | | |

|Individual or Organization | |Phone |

| | | |

|Address | |Fax |

|PURPOSE FOR NEED OF DISCLOSURE: Check applicable categories. |

| At request of individual | Continuing Care | Transferring Care | Case Management | Legal Action |

|Social Security Benefits |Billing |Other (specify): | | |

|In compliance with Wisconsin Statutes, the following require special permission to release otherwise privileged information: |

|Check applicable categories. |

|Mental Health Substance Use* Developmental Disabilities HIV Test Results |

|*I understand that any disclosure made is bound by Part 2 of Title 42 of the Code of Federal Regulations (Final Rule) governing confidentiality of substance use |

|patient records and that recipients of this information may disclose it only in connection with their official duties. |

|INFORMATION TO BE USED &/or DISCLOSED: Check applicable categories. |

|For the Following Date(s): From__________ To Separation from Treatment Courts (If left blank, the last year of information will be disclosed) |

|Specific identification of information is required. Minimum necessary will be disclosed to fulfil request. |

| Final Treatment Summary | Psychological Reports | Treatment Plan |

|Psychiatric Evaluation |Diagnoses |OT/RT Reports |

|Intake Assessment |Medication List |Nutrition Notes/Assessments |

|Doctor Progress Notes/Orders |Nurses Notes |Laboratory/X-ray Reports |

|Social Worker/Case Manager Reports |History & Physical Exam |Records which carry HIV diagnosis |

|Therapy/Counselor Progress Notes |Verbal Communication |Intoxicated Driver Program |

| Other (Please specify): | |

|CLIENT RIGHTS |

|I understand that authorizing the disclosure of this health information is voluntary and I am under no obligation to sign this form and that the covered entity may|

|not condition treatment, payment, enrollment in a health plan or eligibility for health care benefits on my decision to sign this authorization. (However, |

|provision of research-related treatment or treatment that is for the sole purpose of creating health information for disclosure to a third party will not be |

|provided without your written authorization.) I understand that I may inspect or receive a copy of the information to be used or disclosed and a reasonable fee may|

|apply. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by |

|federal privacy standards. Upon request, a list of disclosures can be provided. I understand my HIV test results may be released without authorization to |

|persons/organizations that have access under State law and a list of those persons/organizations is available upon request. I understand that I have a right to |

|revoke this authorization at any time. I understand that the revocation will not apply to information that has already been released in response to the |

|authorization. The consent is subject to revocation at any time except to the extent that the part 2 program or other lawful holder of patient identifying |

|information that is permitted to make the disclosure has already acted in reliance on it. This included the provision of treatment services in reliance on a valid |

|consent to disclose information to a third-party payer. I understand that if I revoke this authorization, I must do so in writing and present my written revocation|

|to Health Information Department. I understand that if I have questions about disclosure of my health information, I can contact the Health Information Management |

|Department at (920) 391-4700. |

|If I fail to specify an expiration date, event, or condition, this authorization will expire in one year or ________________. |

| | | |

|Client Signature or Personal Representative Signature (State Relationship) | |Date and Time |

| | | |

|Witness Signature | |Date and Time |

Revocation

Written Revocation Signature of Client: Date:

Signature of Witness: Date:

Original: Record Copy: Client Revised: 03/03; 6/03; 9/2009; 2/2010, 3/11, 2/12, 8/15, 5/17

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