Release of Information – Mental Health – Client Self-Service – GForm Use this form to document your consent for our communication of your confidential information with other individuals or agencies. Step 1 of 2 50% Our electronic intake and consent forms utilize email communication for transmission of your information. Email and text messaging, while efficient, are relatively insecure. Please be informed that these methods, in the typical form, are not confidential means of communication. While we use encryption to secure the contents of emails sent between our webservers and your inbox, there is still a chance these communications, which may contain confidential information, could be intercepted. The kind the parties that may intercept these messages include, but are not limited to: People in your home or other environments who can access your phone, computer, or other devices that you use to read and write messages. Your employer, if you use work email to communicate with any employee of Minnesota CarePartner. Third parties on the Internet such as server administrators and others who monitor Internet traffic. We offer electronic documentation for convenience and to remove barriers to care. It is not a requirement to receive services. If you'd prefer not to utilize electronic documentation, please do not complete this form, and call us at 612.289.5656 to discuss alternative methods for completing this paperwork. By proceeding past this page, and clicking the box below, you are acknowledging the risks explained above and agreeing to utilize our electronic forms and email communication.Consent* I consent to electronic communication. Today's Date* MM slash DD slash YYYY Are you the client or the parent/guardian?* Client Parent/Guardian Client Name:* First Last Client's Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name of Person Signing this Form*This may be the client, or the parent/guardian. First Last Email of Person Signing Form:*This may be the client or the parent/guardian. A signed copy of this authorization will be sent to this email. Minnesota CarePartner may exchange information with the Agency/Person below:Are you signing a release for a personal contact like a significant other, or a business/agency? * Personal Contact Business/Agency Agency Name:Required if "business/agency" is selected above. Contact Person's Name:Required if "personal contact" is selected above. First Last Contact Phone:Contact Fax:Contact eMail: Contact or Business/Agency Address: Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Nature & Purpose of DisclosureHow may we exchange information with this contact? ** provide to receive from exchange with What type of information may we exchange?*The most common options are pre-selected. Please check/uncheck options to match your preference. Assessments/Summaries Diagnosis Diagnostic Interview Medical History & Physical Neuro/Psychological Testing Case Plans/Notes Discharge Summary Medication Information Urinalysis/Lab Tests Emergency Contact Treatment/Case Plans Consultations Legal Information Psychotherapy Notes Other Other information type: In what format may we exchange information?* Verbally In-Person Conference Written Questionnaire Mailed/Faxed Correspondence Secure/Encrypted eMail Purpose for disclosure:* Assessment/Intake Referral Treatment Planning Case Coordination Discharge Planning Consultation Other: Expiration of AuthorizationTypically, releases of information automatically expire one year from the date signed. This allows us to share the necessary information for the duration of treatment involvement. If you wish to specify an earlier date of expiration, you may do so here. I Don't Need to Change the Expiration Enter a Different Date Alternate Expiration Date MM slash DD slash YYYY First of Two SignaturesYou will sign below, and on the next page. PhoneThis field is for validation purposes and should be left unchanged.
