Authorization for release and disclosure, and/or request for medical information and records - MICHIGAN - Pine Rest Christian Mental Health Services Grand Rapids, MI

If you are receiving your treatment at a clinic location, you must complete the printed form or sign a release at a clinic. The online release is for Telehealth patients only.

Do you want medical information and records sent or received?

Yes
No

Patient Name *

First Last

Patient DOB *

Patient Contact Phone # *

This patient contact phone number will be used in the event we have questions about this release or a records request.

Patient Contact Address *

This patient contact address will be used in the event we have questions about this release or a records request and we can't reach you by phone or if you request that a copy of this release be mailed to you.

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

Email

Form Completed By *

First Last

Relationship to Patient *

I authorize Pine Rest Christian Mental Health Services to: *

(must choose one or both from the list below)

release information from my medical records to the individual/organization listed below
request information from the individual/organization listed below

Name *

Name of the Individual/Organization

Phone *

Phone number for the Individual/Organization

Fax

Fax number for the Individual/Organization

Address *

Address for the Individual/Organization

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

For the following purpose, use, or need:

Appointment Confirmation
Coordination of Care
Other

Check all that apply

Explain:

The following information from my psychiatric/medical records may be disclosed, covering the dates indicated below:

Treatment start date *

Can use birth date if exact start date is unknown.

Treatment end date *

This can be an actual date or a condition (ex.: 12/31/2020, case closure, 60 days after case closure, etc.)

Information for disclosure:

Check all that apply

Treatment Summary
Psychiatric Evaluation
Psychological Testing
Physical Exam
Laboratory Studies
Initial Assessment
Exchange of all written and verbal health information pertinent to the coordination of my care and treatment
Other
Exclude the following information:

Other: *

Description of information to be excluded: *

I acknowledge such information cannot be disclosed without my written informed consent unless otherwise provided by law. I further understand that such information to be disclosed may include treatment of Psychiatric, Substance Abuse, and HIV/AIDS related illnesses. I agree that the information may be faxed for expediency. I have the right to revoke this authorization at any time. Any revocation will be done in writing to the attention of the Medical Records Director and any information previously authorized and released will not be subject to revocation. I acknowledge and authorize that the information indicated on this form will be sent to the individual listed above. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) protects the privacy of health information. Persons or organizations receiving this health information may not be bound by the provisions of this law. However, re-disclosure of this information is prohibited by the Michigan Mental Health Code (sections 748, 749 and 750 of the Public Act 258 of 1974 as amended) and also by Title 42 of the Code of Federal Regulations, Part II, with which this authorization complies. The released information may not be copied, shared or re- released, except as consistent with the authorized purpose stated above. I understand that I am not required to sign this authorization, and that Pine Rest will not refuse me treatment if I refuse to sign. I have the right to inspect and obtain a copy of the information disclosed. A true and exact photocopy/faxed copy of this authorization shall have the same effect as the original.

If no expressed revocation is issued, this authorization will expire one year from the date indicated after my electronic signature or upon the following date, event or condition:

I would like someone to explain this form to me. *

Yes
No

I would like a copy of this release form mailed to me.

Yes
No

This document was completed and submitted by the patient/parent/legal guardian and constitutes an electronic signature for this release of information. *

First Last

Signature Date *

Authorization for release and disclosure, and/or request for medical information and records – MICHIGAN

This online form is for Pine Rest TELEHEALTH patients only.

Authorization for release and disclosure, and/or request for medical information and records - MICHIGAN

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