BH.AFD.FM.020314.IH
Behavioral Health Services
AUTHORIZATION For Use and Disclosure Behavioral Health Services
I hereby authorize AltaMed Health Services Corporation to release/request behavioral health records to the
person/organization named below.
Failure to complete all sections of this form may invalidate this request.
RELEASE INFORMATION FROM:
RELEASE INFORMATION TO:
Patient Name:
Name:
Date of Birth:
Address:
Patient Chart #:
City:
State:
Zip:
Phone #:
Phone#:
Email:
Fax#:
The disclosure of behavioral health records requested herein is meant for the following purpose (Choose only one):
PURPOSE OF INFORMATION TO BE RELEASED:
Personal Use
Second Medical Opinion
Legal Purpose
Further Medical Care
Changing Providers
Social Security Disability
Other (Please Specify):
Dates of Service: From:
/ /
To:
/ /
Or
All Dates of Service
When multiple copies of behavioral health records are requested for multiple purposes, the patient/legal
representative must complete one release/request form for each different purpose.
TYPE OF INFORMATION TO BE RELEASED:
Clinical Therapy Notes
Behavioral Health Notes
Substance Abuse
My Entire Behavioral Health Record to another
Licensed Behavioral Health Provider for
Further Medical Care Only.
My Entire Behavioral Health Record to a
Non-Licensed Behavioral Health Provider;
Not for Further Medical Care.
Other (Please Specify):
METHOD FOR PROCESSING RELEASE:
Mail to Address Listed Above
Patient/Designee/Legal Representative to Pick Up
Fax to Provider Number Above
Other (Please Specify):
If signed by someone other than patient, indicate relationship
Parent/Legal Guardian
Durable Power of Attorney
Caregiver
Personal/Legal Representative
Other (Please Specify):
AltaMed Health Services Corporation
BH.AFD.FM.020314.IH
Patient’s Signature
Date
Witness’ Full Name
Title
Witness’ Signature
Date
The witness must be an Altamed Health Services Corporation employee who has verified the patient’s identity. If a
patient’s legal representative is placing this request, then the witness will verify credentials (i.e, power of attorney, etc) and
file copies of proof in the patient’s record.
NO RELEASE/REQUEST OF BEHAVIORAL HEALTH RECORDS CAN BE PROCESSED WITHOUT THE
SIGNATURE OF THE PATIENT AND WITNESS.
FOR OFFICE USE ONLY
I, a California licensed physician/clinical psychologist/psychiatrist/clinical social worker, am in charge of
and/or supervise this patient’s behavioral health treatment.
As such, I hereby approve disapprove the disclosure of the records requested herein.
Disclosure disapproval reasons:
The patient previously agreed to a temporary denial of access to his/her mental health records only while
he/she (the patient) is part of a research project that includes treatment. Thus, the release of the records
requested herein is prohibited by a patient’s signed consent form. (Provide a copy of the signed consent form).
The patient’s access to his/her behavioral health records are subject to and may be denied under Privacy
Act 5 USC 522a.
The behavioral health record(s) were obtained from someone other that a healthcare provider under a
promise of confidentiality and access to the requested information would reveal the source of information.
An Altamed licensed mental health provider has determined that the access to the requested record is
likely to endanger the life and/or physical safety of the patient and/or another person.
The behavioral health record(s) make reference to another person (unless the person is a healthcare
provider) and a licensed mental health provider has determined that disclosure of the requested records is
likely to cause harm to the patient and/or another person.
The request for access is made by patient’s personal representative (excludes patient’s attorney) and an
Altamed licensed healthcare professional has determined the provision of access to such representative is
likely to cause substantial harm to the individual or another person.
The level of detail requested to be released for the person/entity listed above is considered inappropriate
because he/she is not a licensed mental health provider. In lieu of the record(s) requested, the behavioral
health provider will prepare a summary report that he/she considers is appropriate to release.
See the Approval Guidelines section for detail on the disclosure of records for this request.
Disclosure restrictions:
Indicate which entries you disapprove for disclosure:
Date of entry:
Entry type:
Indicate the entity / individual or any legal representative to whom disclosure should be denied:
Entity and/or individual’s name:
Relationship to the patient:
Approval Guidelines:
The following release/request has been granted:
Release as requested
Full disclosure
Partial disclosure
Limited disclosure
Provider’s Signature:
Degree/s:
Date:
