Coordinated Services Team Initiative (Cst) (Page 5 of 7) in pdf

SAMPLE FORM

REDISCLOSURE NOTICE: The information that I authorize to be released may be redisclosed by the recipient of

the records only if allowed by law. If information is redisclosed, the recipient of the redisclosed information may be

controlled by different laws.

YOUR RIGHTS WITH RESPECT TO THIS AUTHORIZATION:

Right to Inspect or Copy the Health Information to be Used or Disclosed – I understand that I have the right to

inspect or copy the health information I have authorized to be used or disclosed by this authorization form. I may

arrange to inspect my health information or obtain copies of my health information by contacting (insert your

agency’s name and contact information here).

Right to Receive Copy of this Authorization – I understand that if I agree to sign this authorization, I will be

provided with a copy of it.

Right to Refuse to Sign This Authorization – I understand I am under no obligation to sign this form and that the

person(s) and/or organization(s) listed above who I am authorizing to use and/ or disclose my information may not

condition treatment, payment, enrollment in a health plan or eligibility for health care benefits on my decision to sign

this authorization. (Exception: To provide care that is done solely for the purpose of creating information to release

to another party, in which case care cannot be provided without authorizing disclosure. Authorization is needed to

release information to payers for certain mental health services and HIV testing. If I refuse to sign the authorization

form for this purpose, I understand I may be responsible for paying the entire bill for these services.)

Right to Revoke This Authorization –I understand written notification is necessary to cancel this authorization.

To obtain information on how to withdraw my authorization or to receive a copy of my withdrawal, I may contact the

(insert your agency’s name and contact information here).. I am aware that my withdrawal will not be effective

as to uses and/or disclosure of my health information that the person(s) and/or organization(s) listed above have

already made in reference to this authorization.

Expiration date: This authorization is good until one year from the date signed.

I have had an opportunity to review and understand the content of this authorization form. By signing this

authorization, I am confirming that it accurately reflects my wishes.

Date

Signature of Child Listed on Page 1 of this Document

Signature required for release of AODA information if 12 years old or over. Exception: outpatient or

•

detoxification records shall be disclosed only with the consent of the minor if the minor is 12 years or older,

and the minor was the only one to consent to the AODA treatment.

The release of mental health treatment records requires the signature of either a minor over 14 or their

•

parent or guardian.

Date

Signature of Individual Authorizing Release (If signed by other than client, state relationship & authority to do so)

( ) Parent

( ) Guardian ( ) POA for HealthCare

( ) Spouse/Adult Family Member of Deceased Patient

All treatment records or spoken information which in any way identifies a client (patient) are considered confidential

and privileged to the subject individual in compliance with s.51.30, Wis. Stats., DHS 92, Wis. Admin. Code, 42 CFR

Part 2, and 45 CFR Parts 160 and 164. Disclosure without written client (patient) consent or statutory authority is

prohibited by law.

Module 2

Page 22

Coordinated Services Team Initiative (Cst) Page 5

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