Blank Med/Psych

YourPath Care, PLLC Release of Information

Please look over this document to make sure you are OK with YourPath Care sharing your information with other people or organizations. There are different reasons we share this information. Please ask if you want help understanding what we share and why.
Organization name:
Please enter the organization you were referred from
Client Name:*

First NameLast Name
Client Date of Birth:*

MonthDayYear
Date
Client Phone Number:*
Please enter a valid phone number.
Client Email:
example@example.com
Is the client unable to sign for themselves and has a legal representative?*

YesNo/NA
I understand the information to be released or disclosed may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV),mental health and substance use.
I authorize the release or disclosure of the Substance Use Disorder/Mental Health records below:*

All my substance use disorder records. By selecting this option, I understand that these records include all the types of records listed below.Toxicology Results/Urine Drug Screen ResultsAppointmentsMedication(s)AssessmentProgress in TreatmentTreatment PlanInsurance Information/DemographicsDiagnostic InformationDischarge SummarySubstance Use HistoryTrauma History Summary
"All Substance Use Disorder/Mental Health records" includes the following items:
- Toxicology Results/Urine Drug Screen Results
- Appointments
- Medication(s)
- Assessment
- Progress in Treatment
- Treatment Plan
- Insurance Information/Demographics
- Diagnostic Information
- Discharge Summary
- Substance Use History
- Trauma History Summary
What purpose are you authorizing the release of your information for?*

Care, Treatment, and ServicesReferralsLegal/Court Ordered ServicesOther
Entity disclosing my records:

I authorize YourPath Care, PLLC (“YourPath Care”) and my provider(s) of record to disclose my records in accordance with this Consent and Authorization.
IMPORTANT: Please fill out the fields below, failure to do so could result in a delay of services.
My information may be released to (enter organization or individual's name):*
Organization/Individual's Phone Number*
Please enter a valid phone number.
Organization/Individual's Fax Number (if you have it):
Organization/Individual's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Federal and state laws protect the privacy of my records:

I, the above-named client, understand that my substance use disorder records are protected under federal law (including the federal regulations governing the confidentiality of substance use disorder patient records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. Parts 160 and 164) and state law (including the Minnesota Health Records Act, Minn. Stat. §§ 144.291-34), and cannot be disclosed without my written consent unless otherwise provided for by law.
The purpose of this Consent and Authorization for the Release of Substance Use Disorder Treatment Information (this “Consent and Authorization) is to give my written consent to the disclosure of some or all of the records relating to my substance use disorder treatment. I understand that my records, once released pursuant to this Consent and Authorization, may no longer be protected by the above-mentioned federal and state laws.

Revocation and expiration:

I understand that I may revoke this Consent and Authorization at any time by notifying YourPath in writing. I further understand that any such revocation will not apply to disclosure made in reliance on this Consent and Authorization before YourPath received my written notice of revocation.
Unless earlier revoked by me, this Consent and Authorization will expire one (1) year from the date it is signed by me unless earlier revoked by me.
I understand that, upon my request, YourPath will give me a copy of this Consent and Authorization.
Date of client signing:

MonthDayYear
Date
Client Signature*

Clear
If the client is unable to sign due to legal incapacity, the signature of the client's personal representative is required. Documentation of the personal representative’s legal authority will be requested and uploaded into client's electronic medical record.
Representative's Name:
Legal Authority:
Legal Authority phone number:
Please enter a valid phone number.
Legal Authority email address:
example@example.com
Legal Authority Signature:

Clear
Should be Empty:

YourPath Care, PLLC Release of Information