Form MO 650-2616 Authorization for Disclosure of Consumer Medical/Health Information - Missouri

Form MO650-2616 is a Missouri Department of Health and Senior Services form also known as the "Authorization For Disclosure Of Consumer Medical/health Information". The latest edition of the form was released in January 1, 2016 and is available for digital filing.

Download a PDF version of the Form MO650-2616 down below or find it on Missouri Department of Health and Senior Services Forms website.

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StAte oF miSSouRi
AUTHORIZATION FOR DISCLOSURE OF CONSUMER MEDICAL/HEALTH INFORMATION
i, ________________________________________________________________________________ authorize and request
(nAme oF ConSumeR, pARent, guARdiAn/legAl RepReSentAtive)
Check all that apply:
department of mental health (dmh)
department of health and Senior Services (dhSS)
department of Social Services (dSS)
department of elementary and Secondary education (deSe)
any health plan, physician, health care professional, hospital, clinic, laboratory, pharmacy, medical facility or other health care
provider that has provided payment, treatment or services to me or on my behalf.
other ____________________________________________________________________________________________
(nAme oF FACility, AgenCy, mentAl heAlth CenteR, peRSon)
to disclose/release the below specified information of:
nAme
dCn
dAte oF biRth
SoCiAl SeCuRity numbeR
who ReCeived SeRviCeS on (dAteS)
to: (check all that apply)
department of mental health (dmh)
department of health and Senior Services (dhSS)
department of Social Services (dSS)
department of elementary and Secondary education (deSe)
other ________________________________________________________________________________________________
(nAme oF FACility, AgenCy, mentAl heAlth CenteR, peRSon)
____________________________________________________________________________________________________
(AddReSS, City, StAte, zip)
THE PURPOSE OF THIS DISCLOSURE IS (CHECK ALL THAT APPLY)
eligibility determination
Assessment
Aftercare
placement
transfer/treatment
treatment planning
Continuity of Services/Care
Conditional/unconditional Release hearing
At Consumer’s Request
to share or refer my information to other missouri state agencies (such as dmh, dhSS, dSS, deSe, doC, mvC, etc.) to obtain
services consistent with the ____________________________________________ program (please complete the name of the
program in which you want to participate)
other (specify) ________________________________________________________________________________________
do a general medical evaluation, psychological evaluation, orthopedic evaluation, or ________________________ evaluation,
and, if applicable, complete the enclosed im-60A. the examination may include test(s) which are indicated by the patient’s
complaints and are necessary before you can reach a decision on his/her employability. the examination is scheduled for
____________________________ at ____________. the Family Support division will honor a physician’s usual and customary
charges, up to but not exceeding our professional reimbursement schedule. if, in your opinion, the patient must be hospitalized in
order for you to complete this medical report, prior written Authorization by the State medical Review team must be given before
payment will be made by the Family Support division.
THE SPECIFIC INFORMATION TO BE DISCLOSED IS (CHECK ALL THAT APPLY)
discharge Summary
progress notes
treatment plan and/or Review
Social Service Assessment
educational testing, iep, transcript, and/or grading reports protected by 34 CFR part 99
medical/psychiatric Assessment(s), and, if applicable, complete the certification section of the enclosed im-60A.
psychometric testing, including intelligence quotient (iQ) results, neurological testing, or other developmental test results.
other __________________________________________________________________________________________________
hospital’s pertinent data: history and physical, discharge Summary, Consultative exams, lab Reports, Radiology Reports
including mRi and Ct Scans, Cardiology Records, operative Reports, pathology Reports, and emergency Room Records
mo 650-2616 (1-16)
Save
Print
Reset
StAte oF miSSouRi
AUTHORIZATION FOR DISCLOSURE OF CONSUMER MEDICAL/HEALTH INFORMATION
i, ________________________________________________________________________________ authorize and request
(nAme oF ConSumeR, pARent, guARdiAn/legAl RepReSentAtive)
Check all that apply:
department of mental health (dmh)
department of health and Senior Services (dhSS)
department of Social Services (dSS)
department of elementary and Secondary education (deSe)
any health plan, physician, health care professional, hospital, clinic, laboratory, pharmacy, medical facility or other health care
provider that has provided payment, treatment or services to me or on my behalf.
other ____________________________________________________________________________________________
(nAme oF FACility, AgenCy, mentAl heAlth CenteR, peRSon)
to disclose/release the below specified information of:
nAme
dCn
dAte oF biRth
SoCiAl SeCuRity numbeR
who ReCeived SeRviCeS on (dAteS)
to: (check all that apply)
department of mental health (dmh)
department of health and Senior Services (dhSS)
department of Social Services (dSS)
department of elementary and Secondary education (deSe)
other ________________________________________________________________________________________________
(nAme oF FACility, AgenCy, mentAl heAlth CenteR, peRSon)
____________________________________________________________________________________________________
(AddReSS, City, StAte, zip)
THE PURPOSE OF THIS DISCLOSURE IS (CHECK ALL THAT APPLY)
eligibility determination
Assessment
Aftercare
placement
transfer/treatment
treatment planning
Continuity of Services/Care
Conditional/unconditional Release hearing
At Consumer’s Request
to share or refer my information to other missouri state agencies (such as dmh, dhSS, dSS, deSe, doC, mvC, etc.) to obtain
services consistent with the ____________________________________________ program (please complete the name of the
program in which you want to participate)
other (specify) ________________________________________________________________________________________
do a general medical evaluation, psychological evaluation, orthopedic evaluation, or ________________________ evaluation,
and, if applicable, complete the enclosed im-60A. the examination may include test(s) which are indicated by the patient’s
complaints and are necessary before you can reach a decision on his/her employability. the examination is scheduled for
____________________________ at ____________. the Family Support division will honor a physician’s usual and customary
charges, up to but not exceeding our professional reimbursement schedule. if, in your opinion, the patient must be hospitalized in
order for you to complete this medical report, prior written Authorization by the State medical Review team must be given before
payment will be made by the Family Support division.
THE SPECIFIC INFORMATION TO BE DISCLOSED IS (CHECK ALL THAT APPLY)
discharge Summary
progress notes
treatment plan and/or Review
Social Service Assessment
educational testing, iep, transcript, and/or grading reports protected by 34 CFR part 99
medical/psychiatric Assessment(s), and, if applicable, complete the certification section of the enclosed im-60A.
psychometric testing, including intelligence quotient (iQ) results, neurological testing, or other developmental test results.
other __________________________________________________________________________________________________
hospital’s pertinent data: history and physical, discharge Summary, Consultative exams, lab Reports, Radiology Reports
including mRi and Ct Scans, Cardiology Records, operative Reports, pathology Reports, and emergency Room Records
mo 650-2616 (1-16)
1. READ CAREFULLY: i understand that my medical/health information records are confidential. i understand that by signing this
authorization, i am allowing the release of any and all of my medical/health information whether past, present or created in the future up
to the expiration or revocation date of this authorization, unless otherwise indicated. the protected health information (phi) in my medical
record includes mental/behavioral health information. in addition, it may include information relating to sexually transmitted diseases,
acquired immunodeficiency syndrome (AidS), human immunodeficiency virus (hiv), and/or other communicable diseases or
environmental diseases and conditions.
2. this authorization includes both information presently compiled and information to be compiled during the course of treatment at the
above-named facility or agency paying for services, during the specified time frame.
3. unless otherwise indicated, this authorization become effective on the date of signature below and will expire one year from that date.
4. i understand that i have a right to revoke this authorization at any time. i understand that if i revoke this authorization i must do so IN
WRITING and present my written revocation to the health information management department (medical records) or client information
center at this facility. i further understand that actions already taken based on this authorization, prior to revocation, will NOT be affected.
5. i understand that i have the right to receive a copy of this authorization. A photographic copy of this authorization is as valid as the
original.
6. i understand that authorizing the disclosure of this medical/health information is voluntary. i can refuse to sign this authorization. i need
not sign this form in order to assure treatment. i understand that i may request to inspect or request a copy of information to be used or
disclosed, as provided in 45 CFR Section 164.524. i understand that any disclosure of information carries with it the potential for an
unauthorized redisclosure and the information may not be protected by federal confidentiality rules. if i have questions about disclosure
of my medical/health information, i can contact the health information management director (medical records director) or client information
center, or designee, or the privacy officer for this covered entity.
MY SIGNATURE BELOW ACKNOWLEDGES THAT I HAVE READ, UNDERSTAND, AND AUTHORIZE THE RELEASE OF MY PHI.
SignAtuRe oF ConSumeR
dAte
witneSS
dAte
SignAtuRe oF pARent/legAl guARdiAn/RepReSentAtive
(please include a description of Authority to Act on Consumer’s behalf and attach a copy of the document granting Authority, where applicable)
AUTHORIZATION TO DISCLOSE SUBSTANCE ABUSE TREATMENT INFORMATION
Alcohol and drug abuse treatment records are specifically protected by federal regulations (42 CFR part 2) and by signing in the block
below, i am allowing the release of any alcohol and/or drug information records (if any) that i may have to the agency or person specified
on this form. prohibition of Redisclosure: Federal regulations (42 CFR part 2) prohibit the recipient of substance abuse treatment records
from making further disclosure of those records without the specific written authorization of the person to whom those records pertain, or
as otherwise specified by such regulation. A general authorization for disclosure of medical or other information is not sufficient for this
purpose. Sign below if you wish to authorize the release of alcohol and drug abuse information.
SignAtuRe oF ConSumeR
dAte
NOTICE OF REVOCATION
dAte
i, _______________________________________________ , (Consumer) hereby revoke my authorization of this disclosure of information
to the agency/person listed above. this revocation effectively makes null and void any permission for disclosure of information expressly
given by the above authorization. i understand that any actions based on this authorization, prior to revocation, will not be affected.
SignAtuRe oF ConSumeR
dAte
witneSS
dAte
SignAtuRe oF pARent/legAl guARdiAn/RepReSentAtive
dAte
if you choose to revoke your authorization, please provide a copy of the completed revocation to the health information management director
(medical records director), or the client information center, or to the privacy officer of this facility.
mo 650-2616 (1-16)

Download Form MO 650-2616 Authorization for Disclosure of Consumer Medical/Health Information - Missouri

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