Authorization for Behavioral Health and Primary Care Physician to Share Confidential Information

/Authorization for Behavioral Health and Primary Care Physician to Share Confidential Information
Authorization for Behavioral Health and Primary Care Physician to Share Confidential Information 2017-05-18T17:05:22+00:00

MEMBER CONSENT TO RELEASE CONFIDENTIAL INFORMATION

I give permission to and my Primary Care Physician

to share information about my diagnosis and / or treatment related to substance abuse, mental health, or medical history, NOT including the results of a blood test for antibodies to the human immunodeficiency virus (HIV). I understand the purpose of sharing information is to help me receive better care.

This consent form expires 90 days from the date of signing and I can choose to cancel it at any time.

Member Refusal to Release Confidential Information

I DO NOT give permission to and my Primary Care Physician

to share information about my diagnosis and / or treatment related to substance abuse, mental health, or medical history, NOT including the results of a blood test for antibodies to the human immunodeficiency virus (HIV). I understand the purpose of sharing information is to help me receive better care.

This consent form expires 90 days from the date of signing and I can choose to cancel it at any time.

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