MH Release of Information - Staff Requested - eSignature


393 Dunlap St N, Ste 300
Saint Paul, MN 55104
Phone: 612.289.5656
Fax: 651.925.0278

Authorization for the Release of Protected Health Information

Client Name:  

Client Date of Birth:  

Person Signing this Form is the:  

Name of Person Signing this Form:
Name of Staff Member Requesting Signature:

 

By signing this form, I hereby authorize Minnesota CarePartner/Roots Recovery, to: 

 

The following information:


I consent to this information being shared in the following manner:

 

The purpose for this disclosure is:

 

I understand that:

  • My health information is protected by federal regulation (Alcohol and Drug Abuse Patient Records, 42 CFR Part 2: and/or HIPAA 45 CFR) and state privacy laws, and disclosure is allowed only with my authorization except in limited circumstances described in Minnesota CarePartner's Privacy Notice. I understand that I have a right to inspect and receive a copy of my treatment records that may be disclosed to others, as provided under applicable state and federal
  • I can revoke this authorization at any time except to the extent that action has been taken in reliance on it. Minnesota CarePartner's Privacy Notice outlines the procedure for revocation. This authorization will expire in one year from the date I sign or unless I request an earlier expiration by entering a desired date here:  
  • For disclosures other than for treatment, payment and healthcare operations purposes, treatment may not be conditioned on my agreement to sign and authorization (unless I am receiving care solely to create protected health information for disclosure to a third party) (45 CFR & 164.508 (b)(4)(III)
  • Communications resulting from this authorization will reveal that I receive services at Minnesota CarePartner.
  • Federal confidentiality regulations (at 42 CFR Part 2) prohibit re-disclosure of information from alcohol and drug abuse patient records. However, HIPAA requires Minnesota CarePartner to notify me of the potential that information disclosed pursuant to this authorization might be re-disclosed by the recipient and is no longer protected by HIPAA rules.
  • This authorization may be used by Minnesota CarePartner's owned or managed programs upon transfer of my care to them.
  • This information is confidential and will only be used for business purposes and then shredded after 7 years as regulated by HIPAA/confidentiality laws below:

STATUTORY NOTICE:
Information to be disclosed to you from records protected by Federal confidentiality rules (42 CFR part 2). The federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

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Signature Certificate
Document name: MH Release of Information - Staff Requested - eSignature
lock iconUnique Document ID: 924cc1d51799453a4a68f26046000329b5468b1c
Timestamp Audit
June 5, 2020 9:57 am CSTMH Release of Information - Staff Requested - eSignature Uploaded by MInnesota CarePartner - referrals@mncarepartner.com IP 206.84.190.44
June 5, 2020 10:00 am CST Document owner rootsforms@mncarepartner.com has handed over this document to referrals@mncarepartner.com 2020-06-05 10:00:51 - 174.53.135.153
June 5, 2020 10:00 am CSTMinnesota CarePartner - info@mncarepartner.com added by MInnesota CarePartner - referrals@mncarepartner.com as a CC'd Recipient Ip: 174.53.135.153
June 5, 2020 10:17 am CSTMinnesota CarePartner - info@mncarepartner.com added by MInnesota CarePartner - referrals@mncarepartner.com as a CC'd Recipient Ip: 174.53.135.153
June 5, 2020 10:21 am CSTMinnesota CarePartner - info@mncarepartner.com added by MInnesota CarePartner - referrals@mncarepartner.com as a CC'd Recipient Ip: 174.53.135.153
June 5, 2020 11:02 am CSTMinnesota CarePartner - info@mncarepartner.com added by MInnesota CarePartner - referrals@mncarepartner.com as a CC'd Recipient Ip: 174.53.135.153
June 5, 2020 11:03 am CSTMinnesota CarePartner - info@mncarepartner.com added by MInnesota CarePartner - referrals@mncarepartner.com as a CC'd Recipient Ip: 174.53.135.153
June 16, 2020 8:23 pm CSTMinnesota CarePartner - info@mncarepartner.com added by MInnesota CarePartner - referrals@mncarepartner.com as a CC'd Recipient Ip: 75.72.214.61