Release of Information

Authorization to Release Information

This authorization is only valid for the purpose stated below. AngleZ Behavioral Health Services, PA must obtain written authorization before requesting or disclosing any information from or to any other person or agency.
Client Name*

First NameLast Name
Client Email (optional)
example@example.com
Date of Birth*

MonthDayYear
Client ID #
I authorize AngleZ Behavioral Health Services, PA, Phone/Fax: 1-844-294-5306, 841 Riverside Drive Augusta, ME 04330*

To disclose toTo obtain from
Name of Organization*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*

Area CodePhone Number
Fax

Area CodePhone Number
Information exchanged may be:*

WrittenVerbalFaxed
Information to be disclosed or obtained that applies to monitor, assess, and coordinate services identified in your treatment plan with the above noted provider*

Assessment InformationISP/Treatment PlanDischarge SummariesRelevant Financial InfoPsych-Social HistoryPsychiatric Report DiagnosisMedical History/Physical ReportCrisis PlanPsychological/ psychosocial ReportsOngoing Communication for Treatment & Discharge PlanningEducational ReportsAlcohol/Drug TreatmentOther
I Do / Do Not Authorize disclosure of information which refers to treatment or diagnosis of psychiatric illness (Select)*
I Do / Do Not Authorize disclosure of information which refers to treatment or diagnosis of drug/alcohol abuse. I understand that it cannot be re-disclosed without my specific consent. (Select)*
I Do / Do Not Authorize disclosure of information which refers to treatment or diagnosis of HIV, ARC or AIDS. I understand that some individuals about whom such disclosures have been made have encountered discrimination from others in the area of employment, housing, insurance, or social/family relations. (Select)*
I Do / Do Not Wish to review, prior to its release, any information I have authorized for release. (Select)*
This release expires on the date selected below (not to exceed 1 year). This release will automatically expire upon discharge. I understand my right to revoke this authorization at any time. Revocation will not cover prior released material, but will prevent further release of information.

MonthDayYear
Date
I understand that the information indicated is protected and cannot be released without my written permission, unless otherwise permitted by law. My signature below indicates that I have read this release and have had the benefits, risks, and consequences of releasing or not releasing information explained to me. I understand that I have a right to review all materials prior to their release to or from ABHS and that the materials to be released will be reviewed with me upon my request. I understand that I do not need to sign this form to receive services and that I may review ABHS Notice of Privacy Practices before I sign this form.
Client / Guardian Signature:

_________________________________________
Date:

_____________________
AngleZ Staff Signature/Title:

_________________________________________
Date:

_____________________
Mental Health Information: This information has been disclosed from records protected by Maine Statute for confidentiality of mental health information (34-B M.R.S.A.) This information may not be re-disclosed any further without the specific written consent of the person to whom it pertains, or otherwise permitted by law. Substance Abuse Information: This information has been disclosed from records protected by Federal confidentiality regulations (42 C.F.R. Part 2). Federal regulations prohibit any further disclosure without the specific written consent of the person to whom it pertain, or otherwise permitted by such regulations. A general authorization for release of medical or other information is NOT sufficient for this purpose. The federal regulations restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse client.
Should be Empty:

Authorization to Release Information