Release Of Information Template Mental Health

Full Treatment Record Including All Health/Mental Health Information

To release, discuss, or disclose the following: The protected health information to be disclosed includes the following: A mental health release of information form allows mental health practitioners to legally disclose a patient's confidential information to third parties, such as another healthcare provider, an insurance company, or a family member. I understand that the information to be disclosed includes my identity, diagnosis and treatment including alcohol, drugs, genetic testing, behavioral or mental health services, reproductive rights, sexually transmitted & infectious diseases, aids and hiv information, as applicable.

If The Purpose Of This Disclosure Is For The Sale, License To Use Or.

I, the undersigned, understand that a copy of this signed authorization form is as acceptable as the original. Full treatment record excluding the following information: The purpose of this disclosure of information is to improve assessment and treatment planning, share information relevant to treatment and when appropriate, coordinate treatment services. • if the requested information involves mental health information, i acknowledge that i am aware that new jersey has a statutory privilege accorded to confidential communications between a patient and a licensed psychologist and that release of such information may waive this privilege.

Authorization For The Release Of Information Is Not Sufficient For This Purpose For Client Records Applicable Under Federal Law 42 Cfr Part 2.

I authorize the release of any and all of the following medical, mental health and/or substance use disorder information, as specified, which may be contained in my records (check all that apply)with the following date parameters: