Form DMHAS-0037 "Authorization for Release of Information" - Ohio

What Is Form DMHAS-0037?

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

Form Details:

  • Released on October 1, 2013;
  • The latest edition provided by the Ohio Department of Mental Health and Addiction 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 DMHAS-0037 by clicking the link below or browse more documents and templates provided by the Ohio Department of Mental Health and Addiction Services.

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Download Form DMHAS-0037 "Authorization for Release of Information" - Ohio

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AUTHORIZATION FOR RELEASE OF INFORMATION
I,
date of birth
,
hereby authorize
to release my medical information to:
Specific identification of Person or Entity Authorized to Receive information
Dates of Treatment
I authorize the following information to be released:
Narrative Summary
Progress Notes
Records from other providers (specify or "all")
After care Services Plan
Lab Results
Psychiatric Examination
Treatment Plan
History and Physical
Consultation
Other (specify):
Psychology Evaluation
Orders
Social Work Assessment
This authorization includes release of records relating to ("X" apppropriate boxes):
Diagnoses and/or treatment for alcohol and.or drug abuse
HIV test results
AIDS/AIDS Related Complex (ARC) diagnoses and/or treatment
Diagnoses and/or treatment relating to other communicable diseases
Indicate here any additional exceptions or exclusions. If any, to information released:
This authorization for use/disclosure is for the following purpose:
My refusal to sign this authorization will NOT affect my ability to obtain treatment, payment, or enrollment in a health plan. This
authorization will remail effective for 90 / 180 days (circle one) unless an earlier date or condition/event is specified here
. However, I understand that I have the
right to revoke this authorization, in writing, at any time, and that the revocation will be effective except to the extent that ODMHAS has
already taken action in reliance on my authorization. My written statement that I want to revoke my authorization should be delivered to:
Name and Address:
Signature of Individual/Guardian/Personal Representative
Date Signed
Print Name
If this authorization has been signed by a personal representative on behalf of an individual, his/her authority to act on behalf of the
individual must be set forth here:
NOTE:
This information has been disclosed to you from records whose confidentiality is protected from disclosure by State and Federal law.
ORC 5122.31. 42 CFR Part 2, and/or ORC 3701 .243 prohibit you from making any further disclosure of it without the specific and informed
release of the individual to whom it pertains, their authorized representative, or as otherwise permitted by law. A general authorization for
release of information is NOT sufficient for this purpose.
FOR OFFICE USE ONLY
Staff Person Releasing information
Date Information Released
AUTHORIZATION FOR RELEASE OF INFORMATION
Original - Requestor, Copy - Medical Record
DMHAS-0037 (Rev. 10/13)
DMHAS-MedR-1035
AUTHORIZATION FOR RELEASE OF INFORMATION
I,
date of birth
,
hereby authorize
to release my medical information to:
Specific identification of Person or Entity Authorized to Receive information
Dates of Treatment
I authorize the following information to be released:
Narrative Summary
Progress Notes
Records from other providers (specify or "all")
After care Services Plan
Lab Results
Psychiatric Examination
Treatment Plan
History and Physical
Consultation
Other (specify):
Psychology Evaluation
Orders
Social Work Assessment
This authorization includes release of records relating to ("X" apppropriate boxes):
Diagnoses and/or treatment for alcohol and.or drug abuse
HIV test results
AIDS/AIDS Related Complex (ARC) diagnoses and/or treatment
Diagnoses and/or treatment relating to other communicable diseases
Indicate here any additional exceptions or exclusions. If any, to information released:
This authorization for use/disclosure is for the following purpose:
My refusal to sign this authorization will NOT affect my ability to obtain treatment, payment, or enrollment in a health plan. This
authorization will remail effective for 90 / 180 days (circle one) unless an earlier date or condition/event is specified here
. However, I understand that I have the
right to revoke this authorization, in writing, at any time, and that the revocation will be effective except to the extent that ODMHAS has
already taken action in reliance on my authorization. My written statement that I want to revoke my authorization should be delivered to:
Name and Address:
Signature of Individual/Guardian/Personal Representative
Date Signed
Print Name
If this authorization has been signed by a personal representative on behalf of an individual, his/her authority to act on behalf of the
individual must be set forth here:
NOTE:
This information has been disclosed to you from records whose confidentiality is protected from disclosure by State and Federal law.
ORC 5122.31. 42 CFR Part 2, and/or ORC 3701 .243 prohibit you from making any further disclosure of it without the specific and informed
release of the individual to whom it pertains, their authorized representative, or as otherwise permitted by law. A general authorization for
release of information is NOT sufficient for this purpose.
FOR OFFICE USE ONLY
Staff Person Releasing information
Date Information Released
AUTHORIZATION FOR RELEASE OF INFORMATION
Original - Requestor, Copy - Medical Record
DMHAS-0037 (Rev. 10/13)
DMHAS-MedR-1035