"Multi-Party Consent for Release of Information" - Missouri

Multi-Party Consent for Release of Information is a legal document that was released by the Missouri Department of Mental Health - a government authority operating within Missouri.

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Download "Multi-Party Consent for Release of Information" - Missouri

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Multi-Party Consent for Release of Information
Complies with HIPAA and 42 CFR Part 2
Source: Legal Action Center
CONSENT FOR THE RELEASE OF CONFIDENTIAL ALCOHOL OR DRUG AND MENTAL HEALTH INFORMATION
I, ______________________________________________, authorize the following agents:
(Name of patient)
1) ______________________________________________
2) ____________________________________________
(Name of Primary Care Physician or OB/GYN and staff)
(Name of CSTAR Treatment Program)
3) ______________________________________________
4) ____________________________________________
(Name of MO HealthNet Managed Care health plan)
(Name of Managed Care Behavioral Health Organization)
5) Missouri Department of Alcohol and Drug Abuse
6) MO HealthNet Division
to communicate with and disclose to one another the following information [initial each category that applies]:
____
my name and other personal identifying information;
____
my status as a patient in alcohol or drug treatment;
____
initial and subsequent evaluations of my service needs;
____
summaries of alcohol/drug and mental health assessment results and history;
____
summary of alcohol/drug treatment and mental health services plan(s), progress and compliance;
____
attendance in alcohol/drug treatment and mental health services;
____
discharge plan(s) for alcohol/drug treatment and mental health services;
____
date of discharge from alcohol/drug treatment and mental health services, and discharge status:
____
other:_________________________________________________________
The purpose of the disclosures authorized in this consent is to enable the above parties to evaluate my need for services and to
provide and coordinate those services.
I understand that my alcohol and/or drug treatment records are protected under the federal regulations governing Confidentiality of
Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, and cannot be disclosed without my written consent unless otherwise
provided for in the regulations. I also understand that records concerning mental health services I receive are protected by federal
law under HIPAA.
I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it, and
that in any event this consent expires automatically as follows:
(1)
One month following the date I stop receiving services from the alcohol and drug treatment program,
OR
(2)
____________________________________________________
[Specify date if desired]
I understand that generally the alcohol and drug treatment may not condition my treatment on whether I sign a consent form, but
that in certain limited circumstances I may be denied treatment if I do not sign a consent form.
Dated:____________________
__________________________________________
Signature of member
Dated: ___________________
___________________________________________
Signature of witness
Multi-Party Consent for Release of Information
Complies with HIPAA and 42 CFR Part 2
Source: Legal Action Center
CONSENT FOR THE RELEASE OF CONFIDENTIAL ALCOHOL OR DRUG AND MENTAL HEALTH INFORMATION
I, ______________________________________________, authorize the following agents:
(Name of patient)
1) ______________________________________________
2) ____________________________________________
(Name of Primary Care Physician or OB/GYN and staff)
(Name of CSTAR Treatment Program)
3) ______________________________________________
4) ____________________________________________
(Name of MO HealthNet Managed Care health plan)
(Name of Managed Care Behavioral Health Organization)
5) Missouri Department of Alcohol and Drug Abuse
6) MO HealthNet Division
to communicate with and disclose to one another the following information [initial each category that applies]:
____
my name and other personal identifying information;
____
my status as a patient in alcohol or drug treatment;
____
initial and subsequent evaluations of my service needs;
____
summaries of alcohol/drug and mental health assessment results and history;
____
summary of alcohol/drug treatment and mental health services plan(s), progress and compliance;
____
attendance in alcohol/drug treatment and mental health services;
____
discharge plan(s) for alcohol/drug treatment and mental health services;
____
date of discharge from alcohol/drug treatment and mental health services, and discharge status:
____
other:_________________________________________________________
The purpose of the disclosures authorized in this consent is to enable the above parties to evaluate my need for services and to
provide and coordinate those services.
I understand that my alcohol and/or drug treatment records are protected under the federal regulations governing Confidentiality of
Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, and cannot be disclosed without my written consent unless otherwise
provided for in the regulations. I also understand that records concerning mental health services I receive are protected by federal
law under HIPAA.
I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it, and
that in any event this consent expires automatically as follows:
(1)
One month following the date I stop receiving services from the alcohol and drug treatment program,
OR
(2)
____________________________________________________
[Specify date if desired]
I understand that generally the alcohol and drug treatment may not condition my treatment on whether I sign a consent form, but
that in certain limited circumstances I may be denied treatment if I do not sign a consent form.
Dated:____________________
__________________________________________
Signature of member
Dated: ___________________
___________________________________________
Signature of witness