CONSENT TO EXCHANGE INFORMATION WITH PRIMARY …



Consent to Exchange Information with Primary Health Care Provider

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| |Case Number: |      |

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|Consumer Name: |      |Date of Birth: |      |

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|If No Primary Health Care Provider, Referred To: |      |

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|Primary Health Care Provider: |      |

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|Phone #: |      |Fax #: |      | |

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|Health Care Provider’s Address: |      |

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|Staff Person: |      |Phone: |      |

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| Psychiatrist: |      |Phone: |      |

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| |Consumer declined exchange at this time: |Date: |      | |

CLINICAL CONDITION (important symptoms, presentation, diagnosis, etc.)      

| |I authorize the exchange of ALL written and verbal health information to coordinate my care and treatment with my Primary Health Care Provider|

| |and CMHCM staff. If this statement is initialed, then proceed to the authorization and signature section at the bottom of this form |

| |(CONSUMER’S INITIALS REQUIRED). |

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OR:

|I agree that information about my treatment in the following areas can be exchanged with my Primary Health Care Provider and ______________________ |

|staff (CONSUMER INITIAL appropriate items below): |

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|Counseling |

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|Assessments |

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|Laboratory Studies |

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|Medication Management |

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|Psychiatric Evaluation |

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|Psychological Testing |

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|Treatment Summary |

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|Psychiatric Progress Notes |

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|Alcohol and/or Drug Abuse Information |

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|Exclude the following information: |

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|Other, specify: |

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|Human Immunodeficiency Virus (HIV), Acquired Immunodeficiency Syndrome (AIDS) and AIDS Related |

|Complex (ARC) information. |

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|AUTHORIZATION AND SIGNATURE: |

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|I authorize _____________________________ and my Primary Health Care Provider to exchange the information above. I understand that my records are |

|protected under Federal and State law and cannot be disclosed without my written consent unless otherwise provided by law. I understand that this |

|consent expires one year from the date of this release unless I have revoked my consent, either verbally or in writing, prior to this date. |

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|Signature: | |Date: | |

| |(Consumer, Guardian, or Parent of Minor) | |

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|Staff completing form/Witness: | |Date: | |

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| Record of Disclosure of Confidential Consumer Case Information Form completed | |

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