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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