Patient Authorization Disclosure Or Receipt Of Psychotherapy Notes Form (Page 2 of 2) in pdf

Patient Authorization Disclosure Or Receipt Of Psychotherapy Notes Form Page 2

and the recipient may re-disclose the information. However, the recipient may be prohibited from disclosing

substance abuse information under the Federal Substance Abuse Confidentiality Requirements.

I understand that the University of Utah Health Sciences Center will not condition treatment, payment, enrollment

or eligibility for benefits on whether I sign this authorization. I may inspect or copy any information used or

disclosed under this authorization.

I understand that I may revoke this authorization in writing at any time by sending a written revocation of

authorization to: Medical Records, 50 North Medical Drive, SLC UT 84132

I understand that my revocation is not effective to the extent that action has been taken in reliance on this

authorization. This authorization expires (check one):

_____ 1 year from the date below

_____ One time disclosure only

_____ Other: ______________

*Description of Personal Representative Authority:

_______________________________ ___________

Signature of Patient or Representative Date

Parent

Medical Power of Attorney

____________________________________________

Other, explain: _____________________

If Applicable, Name of Personal Representative*

and attach documentation.

Signature must be verified by UUHSC staff or must be notarized. When complete, place in patient’s medical record.

•

_____________________________

______________________________

_________

Signature of UUHSC Staff Member

Printed Name and Employee ID#

Date

•

SUBSCRIBED AND SWORN before me this ____ day of ________________, 20____.

NOTARY PUBLIC

Residing in ________________________________

My Commission expires: _____________________

UUHSC Internal Use Only

Staff Member Processing Request’s Name and Employee ID:

__________________________

Date Received: __________________________

Date Sent to Patient: __________________________

A 30 day extension as been requested. Reason: ___________________________________________

Patient Notified of Extension On: _________________________________________________

Request Processed by (Name and Employee ID): __________________________________________

Fee Charged (if any): _________________________

Patient Authorization Disclosure Or Receipt Of Psychotherapy Notes Form Page 2