Authorization for Release of Protected Health Information ...
Authorization for Release of Protected Health Information for Waitlist Participation
Client Name
Social Security Number
Street Address
Date of Birth
City
State
Zip Code
Phone Number
Name of Provider Agency Referring Client
I authorize
Street Address
City
State Zip Code
to disclose my Protected Health Information, including Mental Health, Drugs and Alcohol and HIV/AIDs
specific information, to:
Broward Behavioral Health Coalition's (BBHC) Network,
Concordia Behavioral Health,
All BBHC-affiliated providers and State Mental Health Treatment Facilities,
OCP2 Evaluators, and
Broward County Homeless Initiative Partnership/Homeless Management Information System (HMIS)/Service Point.
for the purposes of:
Listing me on a secure, centralized, network-wide waitlist,
Decreasing the length of time I have to wait for services I need,
Improving coordination of my care among network providers, Homeless history verification and housing prioritization, coordination and placement, and
OCP2 Referral
I specifically authorize release of the following protected health information, including my Mental Health,
Drugs and Alcohol and, if applicable, HIV/AIDs information:
All of the following behavioral health records as needed to add me to the BBHC waitlist and to secure my
placement with another provider(s) offering services I need: Mental health history, diagnosis and treatment information, including psychiatric and psychosocial
evaluations and excluding psychotherapy notes.
Substance (drug and alcohol) abuse history, diagnosis and treatment information.
HIV/AIDS and other communicable disease test results and diagnosis and treatment information.
Legal records and court documents affecting other providers' willingness to accept me for services.
Protected health information detailing my medical conditions, diagnoses and treatment that affect my placement
and treatment for with an appropriate provider.
HMIS and designated housing provider.
By signing this authorization, I am attesting that I understand:
I can be placed on a centralized, network-wide waitlist that can be viewed by Broward Behavioral
Health Network (BBHC), Concordia Behavioral Health (CBH) and all BBHC-affiliated providers.
My protected health information, including my Mental Health, Drugs & Alcohol and HIV/AIDS information (if
applicable), can be shared with BBHC-affiliated providers and/or HMIS participating organizations who may
provide services to me.
The providers that have access to my protected health information, including my Mental Health, Drugs and
Alcohol and, if applicable, HIV/AIDS information, are prohibited from re-disclosing this information without
my written authorization, except as permitted by federal or state law.
I may revoke this consent at any time; however revocation will not affect any disclosures already made.
Photocopy/Scanned Copy. A photocopy or scanned copy of this form will be as valid as the original.
Expiration of Authorization: This authorization will expire in 12 months or on: _________________, 20___.
Revocation of Authorization: This authorization was revoked by the client on _________________, 20___. This
revocation does not affect any disclosures made in reliance on the original authorization.
Client Signature: _______________________________ Witness Signature: ______________________________
_________________________________________________________________________ _______________________________
Signature of Client or his/her Personal Representative
Date
_________________________________________________________________________ _______________________________
Signature Witness
Date
Broward Behavioral Health Network Providers:
Archways
Gulf Coast Jewish Family and Community Services
Banyan Health Systems
Henderson Behavioral Health
Broward County-Addiction Recovery Center
House of Hope
Broward County-Elderly and Veterans Services
Kids in Distress
Broward County-Office of Justice Services
Mental Health Associates of Broward County
Broward House
North Broward Hospital District ? Broward Health
Broward Housing Solutions
NAMI of Broward County
Broward Partnership for the Homeless
Our Children Our Future
Broward Regional Health Planning Council
South Florida Wellness Network
Broward Sheriff's Office
Susan B. Anthony Recovery Center
Camelot Community Care Care Resource
South Broward Hospital District- Memorial Healthcare System Silver Impact
Chrysalis Center
Smith Mental Health Associates
Citrus Health Network
SunServe
Covenant House of Florida
TaskForce Fore Ending Homelessness
Foot Print to Success Clubhouse
United Way of Broward County
Fort Lauderdale Hospital
Affiliated Providers (Florida State Hospitals):
South Florida State Hospital
South Florida Evaluation and Treatment Center
Florida State Hospital
Treasure Coast Treatment Facility
Northeast Florida State Hospital
Here's Help
West Florida Community Treatment Center
Concept House
North Florida Evaluation and Treatment Center
______________________________________
Signature of Client or his/her Personal Representative
_________________
Date
02.18.2015, Rev. 10.25.2017
................
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