Form DHS-4797C-ENG "Authorization for Release of Protected Health Information - Behavioral Health Home Services" - Minnesota

What Is Form DHS-4797C-ENG?

This is a legal form that was released by the Minnesota Department of Human Services - a government authority operating within Minnesota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2016;
  • The latest edition provided by the Minnesota Department of Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DHS-4797C-ENG by clicking the link below or browse more documents and templates provided by the Minnesota Department of Human Services.

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Download Form DHS-4797C-ENG "Authorization for Release of Protected Health Information - Behavioral Health Home Services" - Minnesota

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Clear Form
*DHS-4797C-ENG*
DHS-4797C-ENG
5-16
Authorization for Release of Protected Health
Information – Behavioral Health Home Services
BEHAVIORAL HEALTH HOME NAME
HEALTH PLAN NAME (if enrolled)
Your behavioral health home (BHH) services provider is listed above. The BHH provider will work with you and the people you
want to help you to coordinate the care that you receive under Minnesota Medical Assistance (MA). This includes the services
that are managed by your health plan and the services that you receive from providers that you list below. In order to do this,
the BHH provider needs to share your protected health information (PHI). PHI is your health information that is protected by
federal and state law.
By signing this form, you are telling the BHH provider that it is okay for the provider and the health care providers and people
listed in Part 3 of this form to share your PHI with each other. You can choose not to give your permission to share your PHI.
If you choose not to give your permission, it will affect your behavioral health home services. Your other Medical Assistance
benefits will stay the same. Your health care providers may still share your PHI even if you do not sign this form, but only in the
way that federal or state law allows. If you have questions, please ask the person who gave you this form to tell you about your
rights or more details about how your health information is shared.
Part 1 - Who is the participant?
I say it is okay for my behavioral health home provider to share the health information listed in Part 2 with my health plan (if I
am enrolled in one) and the health care professionals and people I have listed in Part 3.
PARTICIPANT LAST NAME
PARTICIPANT FIRST NAME
MIDDLE INITIAL
PARTICIPANT ADDRESS
CITY
STATE
ZIP CODE
PARTICIPANT MHCP MEMBER ID
PARTICIPANT PHONE NUMBER
PARTICIPANT DATE OF BIRTH (MM/DD/YYYY)
Part 2 - What protected health information (PHI) can your providers share?
Information about my general physical and mental health and about community supports and services will be shared with my
behavioral health home provider, my health plan (if I am enrolled in one) and all the health care providers and people listed
below in Part 3. This includes information about my medications and any communicable disease (for example, hepatitis) that I
might have. It also includes facts about my mental health and alcohol and drug treatment that might be in my records. This does
not cover psychotherapy notes that are not in my medical record or psychological testing material. IF my records have drug or
alcohol information, I want to share that information as shown below:
Drug and Alcohol Information – IF my records have drug and alcohol information, I want to share it with the BHH provider
listed at the top of this form, the health plan listed at the top of this form and the health care providers and people listed in
Part 3 below.
Yes, all drug or alcohol information can be shared.
Page 1 of 3
Clear Form
*DHS-4797C-ENG*
DHS-4797C-ENG
5-16
Authorization for Release of Protected Health
Information – Behavioral Health Home Services
BEHAVIORAL HEALTH HOME NAME
HEALTH PLAN NAME (if enrolled)
Your behavioral health home (BHH) services provider is listed above. The BHH provider will work with you and the people you
want to help you to coordinate the care that you receive under Minnesota Medical Assistance (MA). This includes the services
that are managed by your health plan and the services that you receive from providers that you list below. In order to do this,
the BHH provider needs to share your protected health information (PHI). PHI is your health information that is protected by
federal and state law.
By signing this form, you are telling the BHH provider that it is okay for the provider and the health care providers and people
listed in Part 3 of this form to share your PHI with each other. You can choose not to give your permission to share your PHI.
If you choose not to give your permission, it will affect your behavioral health home services. Your other Medical Assistance
benefits will stay the same. Your health care providers may still share your PHI even if you do not sign this form, but only in the
way that federal or state law allows. If you have questions, please ask the person who gave you this form to tell you about your
rights or more details about how your health information is shared.
Part 1 - Who is the participant?
I say it is okay for my behavioral health home provider to share the health information listed in Part 2 with my health plan (if I
am enrolled in one) and the health care professionals and people I have listed in Part 3.
PARTICIPANT LAST NAME
PARTICIPANT FIRST NAME
MIDDLE INITIAL
PARTICIPANT ADDRESS
CITY
STATE
ZIP CODE
PARTICIPANT MHCP MEMBER ID
PARTICIPANT PHONE NUMBER
PARTICIPANT DATE OF BIRTH (MM/DD/YYYY)
Part 2 - What protected health information (PHI) can your providers share?
Information about my general physical and mental health and about community supports and services will be shared with my
behavioral health home provider, my health plan (if I am enrolled in one) and all the health care providers and people listed
below in Part 3. This includes information about my medications and any communicable disease (for example, hepatitis) that I
might have. It also includes facts about my mental health and alcohol and drug treatment that might be in my records. This does
not cover psychotherapy notes that are not in my medical record or psychological testing material. IF my records have drug or
alcohol information, I want to share that information as shown below:
Drug and Alcohol Information – IF my records have drug and alcohol information, I want to share it with the BHH provider
listed at the top of this form, the health plan listed at the top of this form and the health care providers and people listed in
Part 3 below.
Yes, all drug or alcohol information can be shared.
Page 1 of 3
Part 3 - Who can my PHI be given to?
Besides the BHH provider and the health plan (if enrolled) listed at the top of this form, my health information may also be
shared with the following health care providers or people: (copy this page before entering information if you want to list more
than five names)
PROVIDER GROUP NAME OR PERSON’S NAME
PHONE NUMBER
ADDRESS
CITY
STATE
ZIP CODE
PROVIDER GROUP NAME OR PERSON’S NAME
PHONE NUMBER
ADDRESS
CITY
STATE
ZIP CODE
PROVIDER GROUP NAME OR PERSON’S NAME
PHONE NUMBER
ADDRESS
CITY
STATE
ZIP CODE
PROVIDER GROUP NAME OR PERSON’S NAME
PHONE NUMBER
ADDRESS
CITY
STATE
ZIP CODE
PROVIDER GROUP NAME OR PERSON’S NAME
PHONE NUMBER
ADDRESS
CITY
STATE
ZIP CODE
Part 4 – Why are you giving out my PHI?
I am agreeing to share my PHI with my behavioral health home team, my health plan (if I am enrolled in one) and the other
health care providers and people that I have listed in Part 3 so they can make sure that my treatments, medications and services
work together and help me reach my health and wellness goals.
Part 5 – Your rights and important facts
It is my decision whether I give permission to share my PHI. I do not have to share my health information. But if I don’t agree
to share my health information, I understand that the behavioral health home services available to me will be very limited.
I may stop this authorization with a written notice at any time, but this written notice will not affect the information my
behavioral health home services provider has already requested.
I do not have to sign this form. If I decide to stop participating in BHH services, I will continue to get all of my other
MA‑covered health care services.
If I want to take back my permission, I must tell my BHH provider listed at the top of this form. I need to do this in writing.
If I need assistance with this process, I can call the DHS Member Help Desk at 651‑431‑2670 or 800‑657‑3729.
Information that is shared from this form may be shared again by those who receive it. If this happens, it may not be protected
by federal or state privacy laws. These laws do not always apply to everyone. But my drug and alcohol information cannot be
shared outside of my behavioral health home providers unless I give my permission again in writing.
If I do not understand or if I have questions, I can get help by calling the DHS Member Help Desk at 651‑431‑2670 or
800‑657‑3729.
Page 2 of 3
DHS-4797C-ENG 5-16
Part 6 – When does my permission to share my PHI end?
My permission to share my PHI lasts from when I sign this form until I am no longer participating in BHH services. It also
ends if I take back my permission. If I have a break in my Medical Assistance coverage and I fix this break within ninety days, I
understand that I will still be with the BHH provider listed at the top of this form. I understand that if I stop being part of the
BHH provider listed at the top of this form my information can be shared between my providers for up to sixty days so that they
can be working together on my care even if I am not covered by Medical Assistance anymore.
Part 7 – Signature of BHH participant
I give my permission to share my PHI as described in this form.
SIGNATURE
DATE
SIGNATURE OF PARTICIPANT’S PARENT
PRINTED NAME OF BHH PARTICIPANT
800-657-3739
Attention. If you need free help interpreting this document, call the above number.
.‫مالحظة: إذا أردت مساعدة مجانية لترجمة هذه الوثيقة، اتصل على الرقم أعاله‬
kM N t’ s M K al’ . ebI G ~ k ¨tU v karCM n Y y k~ ¬ g karbkE¨bäksarenHeday²tKi t «f sU m ehATU r s& B Í t amelxxagelI .
Pažnja. Ako vam treba besplatna pomoć za tumačenje ovog dokumenta, nazovite gore naveden broj.
Thov ua twb zoo nyeem. Yog hais tias koj xav tau kev pab txhais lus rau tsab ntaub ntawv no pub dawb,
ces hu rau tus najnpawb xov tooj saum toj no.
ໂປຣດຊາບ. ຖ ້ າ ຫາກ ທ ່ າ ນຕ ້ ອ ງການການຊ ່ ວ ຍເຫຼ ື ອ ໃນການແປເອກະສານນ ີ ້ ຟ ຣ ີ , ຈ ົ ່ ງ ໂທຣໄປທ ີ ່ ໝາຍເລກຂ ້ າ ງເທ ີ ງ ນ ີ ້ .
Hubachiisa. Dokumentiin kun bilisa akka siif hiikamu gargaarsa hoo feete, lakkoobsa gubbatti kenname bibili.
Внимание: если вам нужна бесплатная помощь в устном переводе данного документа, позвоните по
указанному выше телефону.
Digniin. Haddii aad u baahantahay caawimaad lacag-la’aan ah ee tarjumaadda qoraalkan, lambarka kore wac.
Atención. Si desea recibir asistencia gratuita para interpretar este documento, llame al número indicado
arriba.
Chú ý. Nếu quý vị cần được giúp đỡ dịch tài liệu này miễn phí, xin gọi số bên trên.
ADA1 (9-15)
For accessible formats of this publication or assistance
with additional equal access to human services, write to
DHS.info@state.mn.us, call 800-657-3739, or use your
preferred relay service.
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DHS-4797C-ENG 5-16
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