Outside Provide Agency Consent Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Outside Provider Agency Consent Form AUTHORIZATION FOR USE, DISCLOSURE, AND/OR EXCHANGE OF MEDICAL & MENTAL HEALTH INFORMATION INCLUDING PRIVATE HEALTH INFORMATION UNDER HIPAA AND CONFIDENTIAL ALCOHOL AND SUBSTANCE ABUSE TREATMENT RECORDS UNDER 42 C.F.R, PART 2 Name *FirstLastLayoutPhone Number *DateNATURE AND LIMITS OF INFORMATION TO BE DISCLOSED: I hereby authorize Behavioral Health Clinic. to release the following information contained in my provider records, including confidential alcohol and substance abuse treatment records, inclusive of medical, mental health and other identifying information and confidential communications, any medical records and mental health records as described or defined under Maryland statutory or case law, private health information (PHI) under HIPAA, and, if checked off and initialed in the table below, other information pertaining to my treatment at the above-named facility/provider (all hereinafter collectively “information”). This request authorizes the release, exchange and disclosure of the following information contained in my files. I specifically request the disclosure or non-disclosure of the following information: By electing “Yes” or “No” below, the patient is not admitting to the existence of any said records. Specific Releases: YesNo Admission and Discharge DatesYesAdmission and Discharge Dates YesNoAdmission and Discharge Dates NoTreatment PlansYesTreatment Plans YesNoTreatment Plans NoDiagnosisYesDiagnosis YesNoDiagnosis NoLab ResultsYesLab Results YesNoLab Results NoPsychiatric EvaluationsYesPsychiatric Evaluations YesNoPsychiatric Evaluations NoMedical RecordsYesMedical Records YesNoMedical Records NoProgress In TreatmentYesProgress In Treatment YesNoProgress In Treatment NoMatters Related to Court OrdersYesMatters Related to Court Orders YesNoMatters Related to Court Orders NoTreatment Progress LimitationsYesTreatment Progress Limitations YesNoTreatment Progress Limitations NoDischarge SummaryYesDischarge Summary YesNoDischarge Summary NoAttendanceYesAttendance YesNoAttendance NoOtherYesOther YesNoOther No DISCLOSURE TO BE MADE TO/INFORMATION EXCHANGED WITH: (Include name and phone numbers if known.) LayoutDoctor/psychiatrist:Judge: OtherCircuit Court of:Division of Parole and Probation at:Purpose of Disclosure: YesNo Verification of TreatmentYesVerification of Treatment YesNoVerification of Treatment NoCollaboration of TreatmentYesCollaboration of Treatment YesNoCollaboration of Treatment NoObtain Treatment RecommendationsYesObtain Treatment Recommendations YesNoObtain Treatment Recommendations NoOther:YesOther: YesNoOther: No EXPIRATION DATE/REVOCATION: This authorization automatically expires one year from the date signed below unless revoked in writing sooner by the individual authorizing disclosure in written form to the person or entity to whom or which the disclosure is or was to be made. Revocation for criminal justice referred substance abuse clients is prohibited pursuant to the conditions of 42 C.F.R. Part 2 §§ 2.31 and 2.35. I understand I can ask the court to limit re-disclosure thereafter. Redisclosure/Waiver I also authorize the intended recipient to re-disclose and/or use all or part of the information obtained for purposes of I understand that the protected information herein may only be re-disclosed to those persons or entities specifically designated herein without further protection under HIPAA, Maryland statutes and federal confidentiality regulations for alcohol and substance abuse under 42 C.F.R. Part 2.Miscellaneous A photocopy or facsimile of this authorization and request for release of information shall be deemed as valid as an original. I understand that information may be released in reliance hereon to the extent revocation has not occurred. I understand that benefits may not be conditioned upon signing this authorization. Signature and Date LayoutPatient Signature Clear Signature DateLayoutParent/Legally Recognized Representative Signature Clear Signature Date LayoutWitness Signature Clear Signature Date Submit