Beacon-Auth-Provider-Release_Info

/Beacon-Auth-Provider-Release_Info
Beacon-Auth-Provider-Release_Info 2017-05-18T17:05:22+00:00

I,

authorize Beacon to Request from and authorize: to release/disclose to Beacon Health Options:

Method of Release

Telephone/Verbal (Telephone #)authorize Beacon U.S. Mail/In-person Fax #

I CONSENT TO THE RELEASE OF THE HEALTH INFORMATION INITIALED BELOW:

All information in Beacon’s file

Only information checked below

MailPhoneFaxEmail

I CONSENT TO THE RELEASE OF THE SPECIFIC INFORMATION CHECKED OFF BELOW:

Individual Education Plan (IEP)Speech/Language Eval.Client Information SheetPsych Educ. AssessmentHearing ScreeningIndividualized TreatmentReport Cards/TranscriptsMedical HistoryTreatment Plan ReviewsBehavioral ReportImmunization RecordPsychosocial EvaluationSpecial ReportNeurology ReportBehavioral ProgramPsychological EvaluationPsychiatric EvaluationDischarge SummaryMedication Management VisitsProgress NotesProgress Summary

*Please note information not specifically checked above is not to be released

For date(s) of service: From: To:


THIS INFORMATION IS NEEDED FOR THE FOLLOWING PURPOSE(S):

Coordination of CareCase ManagementPatient CareQuality of Care ReviewOther (Specify)

I understand that my records are protected under state and federal law and cannot be disclosed without my written consent except as otherwise specifically provided by law. Further, I understand that if my records involve alcohol or drug abuse, they are also protected under Federal Regulation 42 CFR Part 2, Confidentiality of Alcohol and Drug Abuse Patient Records. I also understand that disclosure of HIV/AIDS related information may only be: (1) limited to
specific circumstances: and/or (2) restricted by me.

I have read carefully and understand the above statements and expressly and voluntarily consent to disclosure of my confidential health care information (including alcohol and drug abuse records of my condition and HIV/AIDS information, if checked above) to those persons/agencies named above.

I understand that I may withdraw and revoke this consent at any time by notifying Beacon Health Options, either orally or in writing, at the following address:

However, my withdrawal/revocation will not affect the rights of anyone acting in reliance on this consent prior to notice of the withdrawal/revocation. Unless otherwise revoked, this consent will expire on the following date, event or condition: If I fail to specify an expiration date, event, or condition, this consent will remain valid for not more than twelve (12) months from the date this consent was signed.

Beacon will not condition payment, treatment, enrollment or eligibility for benefits on whether I sign this authorization. I am aware that the information disclosed as part of this authorization and contained in my record may be given to another agency/person if requested.

Beacon will not condition payment, treatment, enrollment or eligibility for benefits on whether I sign this authorization. I understand that by not signing this form, the services provided to me by Beacon may be limited if benefits cannot be determined. I am aware that the information disclosed as part of this authorization may be redisclosed and no longer protected under federal or state law.

Signature of Patient, Legal Guardian or Parent: Date:

Relationship if not Patient, or if Patient is under 18: Date:

Signature of Patient, if under 18: Date:

Witness: Date:

This information is needed for the following purpose(s):

Coordination of CareCase ManagementPatient CareQuality of Care ReviewOther (Specify)

I understand that my records are protected under state and federal law and cannot be disclosed without my written consent except as otherwise specifically provided by law. Further, I understand that if my records involve alcohol or drug abuse, they are also protected under Federal Regulation 42 CFR Part 2, Confidentiality of Alcohol and Drug Abuse Patient Records.

I have read carefully and understand the above statements and expressly and voluntarily consent to disclosure of my confidential health care information (including alcohol and drug abuse records of my condition and HIV test results, if checked above) to those persons/agencies named above.

I understand that I may withdraw and revoke this consent at any time by notifying Beacon Health Options, either orally or in writing, at the following address: However, my withdrawal/revocation will not affect the rights of anyone acting in reliance on this consent prior to notice of the withdrawal/revocation. Unless otherwise revoked, this consent will expire on the following date, event or condition: If I fail to specify an expiration date, or condition, this consent will remain valid for not more than twelve (12) months from the date this consent was signed.

Signature of Patient, Legal Guardian or Parent: Date:

Relationship if not Patient, or if Patient is under 18: Date:

Signature of Patient, if under 18: Date:

Witness: Date:

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