Authorization for Release of Medical Information

Facsimile Transmission SBHI-Preble Cover Sheet 2172A US Route 127 North P.O. Box 267 Eaton, OH 45320 (937) 456-1915 – office Date Time

Total Pages Sent: (Including this page)

To Name

Location

Fax Phone #

Immediate Action (15 minute response)  Yes  No

From Name

Location SBHI – Preble / Outpatient Services

Fax Phone # (937) 456-2208

Contact Phone # (937) (937) 456-1915, Clinical Records

CONFIDENTIAL. The federal law prohibits you from making any further disclosure of this information and attached documents unless expressively permitted by the written consent of the person of whom it pertains or otherwise permitted by such regulation (42 CRF Part 2). The information contained in this communication and any accompanying documents is confidential, privileged, and exempt from discussion under applicable law. It is intended only for the use of the recipient or entity named above. If you are not the intended recipient or the person responsible to deliver it to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify us at the telephone number listed above. Please return the original message to us at the above address at our expense.

 Clinical information is confidential and may be released upon proper written consent of the patient or guardian/ parent, if a minor. An SBHI “Authorization of Release of Information” form is attached for your convenience.

 Clinical records and/or information (i.e. testimony) is confidential and may be released upon receipt of a subpoena only if such subpoena is signed by a judge or magistrate or if such subpoena is accompanied by a properly executed, HIPAA-compliant patient authorization or by a proper court order signed by a judge or magistrate. An SBHI “Authorization of Release of Information” form is attached for your convenience.

Upon receipt of the signed ROI, we will be happy to comply with your request. Thank You. SAMARITAN BEHAVIORAL HEALTH, INC. AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION I hereby grant my permission for release, review and exchange of the following information relating to my care between the parties named here. This release is intended to cover all services provided by Samaritan Behavioral Health, Inc. which includes services provided by Samaritan CrisisCare; Youth and Adult Outpatient Services; Young Children Assessment and Treatment Services (YCATS); School-Based Services; Substance Abuse Services; SBHI-Preble; and Miami County Services. Charges for records requests may apply.

I am aware that once this information is released to another party, it may no longer be protected. I understand that I may further limit the type of exchange between the listed parties. List limitation, if any: ______. Samaritan Behavioral Health, Inc. 2172A US Route 127 North P.O. Box 267 AND Eaton, OH 45320 (937) 456-1915 FAX: (937) 456-2208 Phone: FAX: Purpose of this request: (check all that may apply during the timeframe of this release) Continuity of Care / Insurance Patient Legal Other, specify:______Treatment Claim Request Ways information may be shared: (check all that may apply during the timeframe of this release) Phon Shared via Community Patient Health Information Network Mail Fax In Person Picked Up e or Approved Health Information Exchange Network Sent to client via unencrypted e-mail (client Provided to client via unencrypted CD, USB or flash drive (client request only & request only) client pick-up only). Charges for device will apply.

Patient’s Name: Date of Birth: Name at time of treatment: Social Security #: Patient’s Address: Phone #:

 Date Range of Released Information: from ______(SBHI admission date) to SBHI Discharge date (same episode of care);  Other Date Range of Released Information: from ______to ______. This information MAY include treatment or rehabilitation for drug and/or alcohol abuse, psychiatric treatment, HIV Antibody Test (test for AIDS Virus) or AIDS and related conditions, IF they did occur. I specify that this release/exchange is to include:

Mental Health (MH) Assessment Psychiatric Evaluation Drug/Alcohol Abuse Assessment &/or Treatment

MH Treatment Progress / Notes Laboratory Report Occupational Therapy Evaluation &/or Treatment

Treatment Plan - ISP Pharmacological Treatment School records / IEP/outcome measures/progress Discharge Summary Medications Prescribed Court records Consultation Physician Orders Pharmacy / Medication History Primary medical information Other Specified here:

Federal confidentially regulations prohibit the recipient of this released information from making any further disclosure unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The federal rules restrict any use of information to criminally investigate or prosecute any alcohol or drug abuse client.

I understand that this authorization may be revoked at any time in writing, except to the extent that the program or person who is to make the disclosure has already acted in reliance on it. This authorization will remain in effect for 180 days after I sign and date the form below or until ______. I understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my ability to obtain treatment. I understand that I may revoke my authorization at any time and for any reason. I understand that I can lengthen or shorten the authorization period by date, event, or condition.

______For Office Use Only: Signature/Client Date Date Signed by Client/Guardian: ______Authorization Expiration Signature Parent/Guardian Date Date (180 days): If REVOKED, Date of

______Revocation: Witness Date Extended Date From to Signature Date If the signature is not that of the client/patient, explain, including authority to sign on behalf of the client and documentary evidence provided. ______. BHI-098 (7-29-14) SBHI-Preble.