Form AW-18 "Release of Protected Health (Phi) Consent Form" - Nevada

What Is Form AW-18?

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

Form Details:

  • The latest edition provided by the Nevada Department of Health and Human Services;
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Download a printable version of Form AW-18 by clicking the link below or browse more documents and templates provided by the Nevada Department of Health and Human Services.

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Download Form AW-18 "Release of Protected Health (Phi) Consent Form" - Nevada

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DIVISION OF PUBLIC AND BEHAVIORAL HEALTH
RELEASE OF PROTECTED HEALTH (PHI) CONSENT FORM
Name: _______________________________________________ Date of Birth: _____________SS #: XXX-XX-_________
Street Address: ________________________________________City: __________________State: ______ Zip: _________
Phone #:________________________________________Alt. #: ________________________________________________
I authorize the following Agency to release my Protected Health Information (PHI) for the specified dates:
LAKE’S CROSSING: Dates of Service: __________________________________________________________
NNAMHS: Dates of Service: _____________________________________________________________________
RURAL HEALTH CLINIC
Dates of Service: ___________________________________________________
SNAMHS:
_____Rawson-Neal _____ Stein_____ Medication Clinic Dates: ___________________________
OTHER: _____________________________________________________ Dates: ___________________________
INFORMATION TO BE RELEASED: (Individual MUST INITIAL each item of information to be released)
_____ Psychiatric/Drug/ Alcohol Information
_____HIV/AIDS Information
______Consultation Reports
_______History & Physical Exam
______Treatment Plans
______Diagnosis (psychiatrist)
_______Discharge Summary
______ Outpatient Counseling
______Psychiatric Evaluation
_______Medication Records
______ Service Coordination
______Psychological Assessment
_______ Progress Notes
______ Case Management
______General Summary Letter Only
_______ Nursing Notes
______ Lab / EKG Results
______Other (Specify):__________________________________________________________________________________________________________
RELEASE TO:
Name/Agency (Recipient Name): _______________________________________________
Phone#: ________________
Street Address: __________________________________City: ___________________State: ________ Zip: ___________
MUST BE INITIALED: ______Written Disclosure _____Verbal Disclosure ______Transmitted electronically__________
Electronic transfer/E-mail address: __________________________Fax #: (If different from above) ______________________
PURPOSE OF RELEASE:
_____ Continuation of Care
_____ Self/Personal
_____ Insurance
Specify Purpose: ___________________________________________________
_____ Legal
INFORMATION FOR INFORMED CONSENT
The confidentiality of medical, psychiatric and substance abuse information is protected by State and Federal Statutes, Rules and Regulations including
Nevada Revised Statutes and Title 42 of the Code of Federal Regulations. These Statutes, Rules and Regulations require that the individual give informed
consent prior to the release of any health/hospital records or information, except as specifically provided for within the Statutes, Rules and Regulations. Any
violation of these regulations may be directed to the United States Attorney for the judicial district in which the violation occurs. A general authorization for
the disclosure of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate
or prosecute any alcohol or drug abuse patient. Re-disclosure of information pertaining to identification of an individual as having been diagnosed, treated, or
referred for treatment for a substance use disorder is prohibited.
Consent to release information will be considered valid only when it states: (1) who will release the information; (2) who will receive the information; (3) the
purpose for which the information will be used; (4) what specific information will be released; and (5) when the consent will expire. The consent must contain
the individual’s or authorized representative’s signature and the date of the signature. The authorized representative signing for the client must submit a copy
of the legal document(s) granting this authority.
This authorization for the Release of Medical Information waives any and all rights that the individual now has or in the future may have to bring any legal
action against the releasing person/facility for any damages caused directly or indirectly by the release of this information or other confidential information.
Upon request, the individual will be given a copy of the completed “Authorization for the Release of Protected Health Information.”
This authorization is effective immediately and is subject to revocation in writing at any time, except to the extent that action has already been taken in reliance
thereon. Otherwise, this authorization expires________ days from the date of signing (but no longer than 365 days) or upon case closure, whichever occurs
first.
A PHOTOCOPY, FACSIMILE OR ELECTRONIC SUBMISSION OF THIS FORM IS AS VALID AS THE ORIGINAL
Client or Legal Representative Signature:
_______________________________ Date: __________________
Relationship to Client
Witness Signature:
: __________________________________
_______________________________________
Guardians and Durable Power of Attorney designees should include a copy of the applicable paperwork with this request)
COPIES $.60 PER PAGE
AW-18 ENG
Side 1
REVOCATION over
DIVISION OF PUBLIC AND BEHAVIORAL HEALTH
RELEASE OF PROTECTED HEALTH (PHI) CONSENT FORM
Name: _______________________________________________ Date of Birth: _____________SS #: XXX-XX-_________
Street Address: ________________________________________City: __________________State: ______ Zip: _________
Phone #:________________________________________Alt. #: ________________________________________________
I authorize the following Agency to release my Protected Health Information (PHI) for the specified dates:
LAKE’S CROSSING: Dates of Service: __________________________________________________________
NNAMHS: Dates of Service: _____________________________________________________________________
RURAL HEALTH CLINIC
Dates of Service: ___________________________________________________
SNAMHS:
_____Rawson-Neal _____ Stein_____ Medication Clinic Dates: ___________________________
OTHER: _____________________________________________________ Dates: ___________________________
INFORMATION TO BE RELEASED: (Individual MUST INITIAL each item of information to be released)
_____ Psychiatric/Drug/ Alcohol Information
_____HIV/AIDS Information
______Consultation Reports
_______History & Physical Exam
______Treatment Plans
______Diagnosis (psychiatrist)
_______Discharge Summary
______ Outpatient Counseling
______Psychiatric Evaluation
_______Medication Records
______ Service Coordination
______Psychological Assessment
_______ Progress Notes
______ Case Management
______General Summary Letter Only
_______ Nursing Notes
______ Lab / EKG Results
______Other (Specify):__________________________________________________________________________________________________________
RELEASE TO:
Name/Agency (Recipient Name): _______________________________________________
Phone#: ________________
Street Address: __________________________________City: ___________________State: ________ Zip: ___________
MUST BE INITIALED: ______Written Disclosure _____Verbal Disclosure ______Transmitted electronically__________
Electronic transfer/E-mail address: __________________________Fax #: (If different from above) ______________________
PURPOSE OF RELEASE:
_____ Continuation of Care
_____ Self/Personal
_____ Insurance
Specify Purpose: ___________________________________________________
_____ Legal
INFORMATION FOR INFORMED CONSENT
The confidentiality of medical, psychiatric and substance abuse information is protected by State and Federal Statutes, Rules and Regulations including
Nevada Revised Statutes and Title 42 of the Code of Federal Regulations. These Statutes, Rules and Regulations require that the individual give informed
consent prior to the release of any health/hospital records or information, except as specifically provided for within the Statutes, Rules and Regulations. Any
violation of these regulations may be directed to the United States Attorney for the judicial district in which the violation occurs. A general authorization for
the disclosure of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate
or prosecute any alcohol or drug abuse patient. Re-disclosure of information pertaining to identification of an individual as having been diagnosed, treated, or
referred for treatment for a substance use disorder is prohibited.
Consent to release information will be considered valid only when it states: (1) who will release the information; (2) who will receive the information; (3) the
purpose for which the information will be used; (4) what specific information will be released; and (5) when the consent will expire. The consent must contain
the individual’s or authorized representative’s signature and the date of the signature. The authorized representative signing for the client must submit a copy
of the legal document(s) granting this authority.
This authorization for the Release of Medical Information waives any and all rights that the individual now has or in the future may have to bring any legal
action against the releasing person/facility for any damages caused directly or indirectly by the release of this information or other confidential information.
Upon request, the individual will be given a copy of the completed “Authorization for the Release of Protected Health Information.”
This authorization is effective immediately and is subject to revocation in writing at any time, except to the extent that action has already been taken in reliance
thereon. Otherwise, this authorization expires________ days from the date of signing (but no longer than 365 days) or upon case closure, whichever occurs
first.
A PHOTOCOPY, FACSIMILE OR ELECTRONIC SUBMISSION OF THIS FORM IS AS VALID AS THE ORIGINAL
Client or Legal Representative Signature:
_______________________________ Date: __________________
Relationship to Client
Witness Signature:
: __________________________________
_______________________________________
Guardians and Durable Power of Attorney designees should include a copy of the applicable paperwork with this request)
COPIES $.60 PER PAGE
AW-18 ENG
Side 1
REVOCATION over
DIVISION OF PUBLIC AND BEHAVIORAL HEALTH
RELEASE OF PROTECTED HEALTH (PHI) CONSENT FORM
REVOCATION:
I hereby revoke the authorization given on the reverse side of this page
Date/Time______
Signature of Patient
Date/Time_____
Signature of Guardian/Representative (Legal documents required)
Date/Time_____
Signature of Witness
Side 2
Page of 2