"Authorization to Release Information" - Maine

Authorization to Release Information is a legal document that was released by the Maine Department of Health and Human Services - a government authority operating within Maine.

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Authorization to Release Information
We are committed to the privacy of your information.
Please read this form carefully.
Which office(s) should help you? Please check.
Office of MaineCare Services
Office of Behavioral Health
Office for Family Independence and Medical Review Team
Office of Child and Family Services
Maine Center for Disease Control and Prevention
Office of Aging and Disability Services
Dorothea Dix Psychiatric Center
Office of Administrative Hearings
Riverview Psychiatric Center
Other:
Division of Licensing and Certification
Other:
Whose information will be disclosed? Please print clearly.
Individual’s Name
Date of Birth
Home Address
Town/City
State
Zip Code
Telephone
Email address of individual/personal representative (optional)
Please check:  Release/Send my information to:  Obtain/Get my information from:
Name of Individual
Organization
Address
Town/City
State
Zip Code
Telephone
Email address (optional)
What is the purpose of the disclosure?
Personal request
To coordinate or manage my care
For a legal matter, including testimony
To see whether I qualify for insurance coverage, services, or benefits
Other:
To share the information with others by EMAIL, please
initial and complete the following.
I understand that email and the internet have risks that the office sharing my information cannot control. It is possible
that my emailed information could be read by a third party. I ACCEPT THOSE RISKS and still ask to send my
information by email. INITIAL HERE ______
Please print the email address where you want your information sent:
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DHHS authorization 2020
Authorization to Release Information
We are committed to the privacy of your information.
Please read this form carefully.
Which office(s) should help you? Please check.
Office of MaineCare Services
Office of Behavioral Health
Office for Family Independence and Medical Review Team
Office of Child and Family Services
Maine Center for Disease Control and Prevention
Office of Aging and Disability Services
Dorothea Dix Psychiatric Center
Office of Administrative Hearings
Riverview Psychiatric Center
Other:
Division of Licensing and Certification
Other:
Whose information will be disclosed? Please print clearly.
Individual’s Name
Date of Birth
Home Address
Town/City
State
Zip Code
Telephone
Email address of individual/personal representative (optional)
Please check:  Release/Send my information to:  Obtain/Get my information from:
Name of Individual
Organization
Address
Town/City
State
Zip Code
Telephone
Email address (optional)
What is the purpose of the disclosure?
Personal request
To coordinate or manage my care
For a legal matter, including testimony
To see whether I qualify for insurance coverage, services, or benefits
Other:
To share the information with others by EMAIL, please
initial and complete the following.
I understand that email and the internet have risks that the office sharing my information cannot control. It is possible
that my emailed information could be read by a third party. I ACCEPT THOSE RISKS and still ask to send my
information by email. INITIAL HERE ______
Please print the email address where you want your information sent:
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DHHS authorization 2020
What information should be released or obtained? Please check all that apply.
Special permission: Drug/Alcohol Treatment or Referral
General permission:
for Services
 All health information from the office(s) checked
 Include all drug/alcohol information in the release
above
 Claims or encounter data (information about visits
 Include only the specific drug/alcohol records checked:
to health care providers)
 Diagnosis and treatment
 Billing, payment, income, banking, tax, asset, or data
 Clinical notes and discharge summaries
needed to see if you qualify for DHHS program
Drug/Alcohol history or summary
benefits
 Payment or claims information
 Limit to the following date(s) or type(s) of information:
 Living situation and social supports
(for example “Lab test dated June 2, 2019” or “Claims
 Medication, dosages or supplies
from 2018-2020”)
 Lab results
 Other: ____________________________________
 Other:
Special permission: Mental/Behavioral Health Services
Special permission: HIV/AIDS Status/Test Results
 Include this information in the release
 Include this information in the release
 I want to review my mental health/behavioral health
Please note: Maine law requires us to tell you of possible
record before release. I understand that the review will
effects of releasing HIV/AIDS information. For example,
be supervised.
you may receive more complete care if you release this
information, but you could experience discrimination if it is
Please note: Maine law allows us to share this information
misused. Your HIV/AIDS-related information, and all of
with other health care providers and health plans to
your data, will be protected as the law requires.
coordinate and manage your care (to help take care of you)
so long as we make a reasonable effort to notify you of the
release.
I understand and agree that:
I am signing this form voluntarily. I have the right to a signed copy of this form if I request one.
My treatment, payment for services, or benefits will not depend on whether I sign this form unless I am requesting or
disclosing information to apply for benefits.
“Information” may be in written, spoken and/or electronic format, and includes information about me from other
healthcare providers (such as doctors, hospitals, and counselors) that is included in my files. My signature allows the
people/offices named on the reverse to discuss my information for the purposes noted on this form.
My information will be kept confidential as required by law. If I choose to share my information with others who are
not required by law to keep it private, it may no longer be protected by federal confidentiality laws.
If alcohol or drug treatment or program (substance use disorder) records are included in this release, a notice will be
included with the records saying that such information may not be re-released or shared without my written permission.
I may revoke (take back) my permission to release my information by filling out the Revocation Form found at
http://www.maine.gov/dhhs/privacy/index.shtml
and sending it to the office that shared my information. The
Revocation Form is effective only after it is received and does not apply to information that was already shared.
If I take back my permission or refuse to release some or all of my information, my choice could lead to an improper
diagnosis or treatment, or denial of insurance.
This form expires one year from the date below unless I write an earlier date here: _____________________
This form permits additional releases until it expires.
Date:
Signature:
Personal Representative’s authority to sign:
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DHHS authorization 2020
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