Mental Health Authorization to Release Info

Initial Action*

Keep On File (for future use)
Send Records (to agency/name listed below)
Request Records (from agency/name listed below)

(What would you like done with the release?) NOTE: If nothing is checked, release will be placed on file for future requests.

Legal Name*

First Last

Date of Birth*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

I Authorize Nystrom & Associates, LTD. and Family Support Services INC. (All Locations)

To do the following:*

Release to
Receive from

Agency/Name*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Fax

Information to be Released

What do you want sent or released?*

Only release records checked below*

Most Recent Diagnostic Assessment
Diagnostic Assessment, 3 most recent Progress Notes and Treatment Plan
Psychological Testing Interpretive Report
Itemized Billing Statement
Other

NOTE: Unless otherwise indicated, all related records regarding Mental Health will be included. This does not include records legally defined as Psychotherapy notes.

Please specify*

From:*

To:*

Method of Communication

How would you like the information communicated/sent? Check Appropriate box(es):

Electronic Methods:

Standard Email (PDF)
Secure Email (PDF)
FollowMyHealth (Requires FollowMyHealth)
CD (Password Protected PDF)

NOTE: Transmission of records via standard email is not a secure method of transmission. By choosing email, I understand that I risk my information being intercepted by an unauthorized individual.

Email*

Enter Email Confirm Email

By providing your email address, you're giving consent for us to contact you via this method.

Standard Methods:

Verbal/Phone
Fax
Pick-up
Mail

Purpose of Release

Why is it needed?*

Coordination of Care
Social Security Appeal
Social Security Disability
Insurance Payment/Claim
Litigation/Legal
Personal Use/Review
Other

NOTE: Purpose for release is not required if you are requesting your own records for personal use/review. Records sent to a third party must identify a purpose

Other:

Representative's relationship to patient (parent, guardian, etc.)

Name (If not signed by patient)

NOTE: If signed by someone other than the patient, we need written proof of authority.

Comments/Notes

Signature

I understand the following: a. I have a right to revoke this authorization in writing at any time, except to the extent information has been released according to this authorization. b. The information released in response to this authorization may be re-disclosed to other parties. c. My treatment or payment for my treatment cannot be conditioned on the signing of this authorization. d. Communications resulting from this authorization will reveal I have received services from NAL/FSSI. e. My health information is protected by federal regulations and state laws. Disclosure is only allowed with my authorization, except in limited circumstance as described in NAL/FSSI Privacy Policy. f. I have the right to inspect and receive a copy of my treatment records that may be disclosed to others, as provided under applicable state and federal laws. A photocopy of this authorization will be treated in the same manner as the original. This authorization shall be in force and effect until 1 year from date of execution at which time this authorization expires, unless an earlier date is indicated in the comments/notes section below. *Fees may be charged in accordance with MN Statute 144.292 and Federal Rule 45 C.F. R. §164.524

Consent*

By checking this box, I attest that I am the individual identified above. I agree my electronic signature is the legal equivalent of my manual signature on this form.

Date*

Guidelines for completing your Authorization for Releasing of Confidential Information

Nystrom & Associates, Ltd. (NAL), and Family Support Services, Inc. (FSSI), recognizes the importance of patient confidentiality as well as the importance of coordinating care and treatment with other professionals, family, friends, and others involved in your care. Please review all items on this form and contact NAL/FSSI with any questions concerning this form at the below listed offices or website. Patient Information: Complete this entire section with clear and legible writing so the information easily identifies the patient whose information is being requested/released. To Do the Following: Indicate clearly and legibly where or whom you wish to send/receive information from.Be as Specific as you can. ALSO, please check by either: (1) Release to, and/or (2) Receive from, If you choose only to Receive information your NAL provider CANNOT share any information; if you choose Release only your NAL provider can only share information; if you choose both to Release AND Receive they may share and take in information from the agency/name listed on the form. Information to be Received/Released: The purpose of this section is to indicate what information you wish to be shared. Please select the appropriate box or write in date range. Selecting Any/All authorizes NAL/FSSI to share or send your entire medical record. Method of Communication: Use this space to indicate what method you would like records transmitted. If you would only like NAL/FSSI to have verbal communicate with the identified person/agency, select the Verbal/Phone option. If you wish records to be transmitted to the person or agency, select one of the other available options. If you are requesting a copy of your own records, we encourage you to use one of the available electronic methods so you can quickly and easily get access to your records Purpose of Release: Identify the reason you need to release/request information. This helps NAL/FSSI appropriately provide care and track releasing confidential information. It informs us who may be responsible for the cost of medical records being released and is required on each release. * Fees may be charged in accordance with MN Statute 144.292 and Federal Rule 45 C.F. R. §164.524 (when applicable). Authorization and Revocation: Signing this form (or having the legal guardian sign for a patient) will grant authorization to share/receive confidential information. Please sign and date this form to validate this authorization. If signed by someone other than the patient, you will be required to provide written proof of your authority. Unless otherwise noted this consent will automatically expire in one year from the date signed. The authorization can be revoked or can be edited at any time at your written direction to our organization. Helpful Tips: If requesting records, please allow 7-10 business days for processing of the Release of Information. In some cases it can take up to 30 days (45 CFR §164.524(b)(2)(i).

CALL NOW (1-844-697-8766)

contactus@nystromcounseling.com

Authorization to Release and Disclose Patient Information