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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