Authorization To Disclose Records {DHSH 17-063}

Authorization AUTHORIZATION TO DISCLOSE DSHS RECORDS OF: NAME LAST FIRST MIDDLE DATE OF BIRTH The following information may help in locating records: CLIENT IDENTIFICATION NUMBER FORMER NAMES OTHER IDENTIFICATION NUMBER DATES OF SERVICE LOCATION OF SERVICE DISCLOSE TO: NAME LAST FIRST MIDDLE TITLE ORGANIZATION OR BUSINESS NAME IF APPLICABLE ADDRESS CITY STATE ZIP CODE TELEPHONE NUMBER (INCLUDE AREA CODE) FAX NUMBER (INCLUDE AREA CODE) E-MAIL ADDRESS REASON FOR DISCLOSURE (NOT REQUIRED) AUTHORIZATION: SOURCES: I authorize the following DSHS programs to disclose or give access to confidential information about me as described below. Information may be provided verbally or by computer data transfer, mail, fax, or hand delivery. The following programs only (check all that apply): Behavioral Health and Recovery (DBHR) Children's Administration (CA) Child Support (DCS) Community Services (CSD ­ public assistance) Developmental Disabilities (DDA) Home and Community Services (HCS) Juvenile Rehabilitation programs Residential Care Services (RCS) Vocational Rehabilitation (DVR) State Mental Health Institutions (ESH, WSH, CSTC) Special Commitment Center (SCC) Human Resources Division Other: All parts of the Department of Social and Health Services (DSHS) RECORDS: I authorize the following DSHS records to be disclosed: Client records held by parts of DSHS marked above All my client records Other confidential records held by parts of DSHS marked above Records on the attached list Personal information in employment-related records The following records only: I want to limit the records to be disclosed as follows (by date, type of record, etc.): PLEASE NOTE: If your client or other confidential records include any of the following information, you must also complete the below section to allow disclosure of these records. SPECIAL RECORDS: I give my permission to disclose the following information held in DSHS records (check all that apply): HIV/AIDS and STD test results, diagnosis or treatment records (RCW 70.02.220) Mental health records (RCW 70.02.230 or 240) Chemical Dependency (CD) records (42 CFR Part 2) · · · · This permission is valid for 180 days or until (date or event, if not checked, will be 180 days). I may revoke or withdraw my permission in writing at any time, but that will not affect information already produced. I understand that my records may no longer be protected under the laws that apply to DSHS after this they are produced. A copy of this form is valid to give my permission to disclose records. DSHS may charge to provide copies of its records. DATE SIGNED TELEPHONE NUMBER (INCLUDE AREA CODE) AUTHORIZED BY (SIGNATURE) PRINT NAME WITNESS/NOTARY (SIGN AND PRINT NAME, IF APPLICABLE) If I am not the person who is the subject of the records, I am authorized to sign because I am the: (attach proof of authority) Parent of minor Legal Guardian Personal Representative Other: Notice to those receiving information: If these records contain information about HIV, STDs, or alcohol or drug abuse, you may not further disclose that information under federal and state law without specific permission of the subject and meeting specific legal requirements. AUTHORIZATION DSHS 17-063 (REV. 02/2016) PAGE 1 OF 2 American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR COMPLETION OF AUTHORIZATION FORM Purpose: You should use this form when you want DSHS to be able to disclose confidential information about you to another person (including an attorney, a legislator, or a relative). You may give permission to disclose all confidential records DSHS has about you or you may limit your permission to specific records or parts of the agency. This form will also permit DSHS to discuss your situation verbally with the person you authorize. Notice to Clients: Most client information DSHS has is confidential and will not be disclosed to others unless you grant permission or if disclosure is allowed by law. After DSHS discloses your confidential information, please be aware that the recipient may not protect your records under the same laws that apply to DSHS. DSHS cannot refuse you benefits if you do not sign this form to allow disclosures to DSHS unless your authorization is needed to determine eligibility. For information on how DSHS health care components covered by HIPAA share protected health information and your privacy rights, please consult the DSHS Notice of Privacy Practices at www.dshs.wa.gov or ask the person who gave you this form. You may get a copy of this form. Use: You may fill out this form electronically or by hand. Use the tab key on a computer to move between fields. A separate form must be completed for each person whose records are requested, including children. "You" refers to the subject of the records. Parts of Form: IDENTIFICATION OF SUBJECT OF RECORDS: · Name: Provide your full name or the name of the person whose records are requested if you are acting for someone else. · Date of birth: Please include this information needed to identify you from persons with similar names. OPTIONAL INFORMATION to help locate records: · Former names: Include any other names that have been used when receiving benefits or services. · Client identification number: Provide any number that DSHS may have assigned. · Other identification number: Include any other identifier that could help locate DSHS records. Only provide a social security number if necessary. · Date and location of services: Provide this information to help DSHS identify and locate the records you want disclosed. PERSON RECEIVING RECORDS: · Identification: Please fill out this section as fully as possible so we can contact the person or organization who will have access to your confidential information. · Reason for Disclosure: This information is required before DSHS can share drug and alcohol or mental health records. If you do not fill in this field, DSHS will note the reason for disclosure as being at your request. AUTHORIZATION: · Parts of DSHS: Please mark either the parts of DSHS you want to disclose records or mark the bottom box in this section if you want to give access to any records DSHS has about you. Write in the name of program in "Other" if not in the list. · Information disclosed: Indicate what records that you want disclosed. You may allow disclosure of all or part of your DSHS client or other confidential records. You may also limit disclosure to client records held only by the parts of the agency marked in