Authorization to Release Medical Records

Please fill out all required fields to authorize the disclosure of clinical information.

1 Client Information

Client Name *

Date of Birth *

Client # (Optional)

2 Release Information To

I give permission to CMHA-CEI to release clinical information pertaining to my, my child's, or my ward's care to:

Organization / Recipient Name *

Address, City, State, Zip *

Email Address

Phone Number

Fax Number

3 Delivery Method & Scope

I would like my records provided via:

Encrypted Email Fax Mail Paper (Pick Up)

Date Range of Records Requested Cannot be future dated

From

Reason for Release (Optional if you are an authorized individual)

4 Documents Requested

Select all clinical and evaluation documents you would like to include in this release:

Other:

Acknowledge & Understand

This authorization will last no longer than reasonably necessary to serve the purpose for which it is given.
I have read, or have had read to me, this authorization form and understand that:
- I may withdraw this authorization at any time, unless action has already been taken based on this authorization.
- This record may contain mental health, drug and/or alcohol use/abuse history, HIV, AIDS, or ARC information, as applicable to my/my child's/my ward's case.
- That appropriate information from my clinical record may be released when needed for immediate client care (as defined in clinical policies 3.3.10 and 3.2.14).

5 Consent Signature

Client / Parent / Guardian Signature

Relationship to Client

Date Signed

Witness to Signature (If applicable)

Witness Relationship

Date Witnessed

Confidentiality of Alcohol and Drug Abuse Records Disclosure:

This information has been disclosed to you from records whose confidentiality is protected by Federal regulations which prohibit you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations. Further disclosure of this information is prohibited unless otherwise permitted by Federal and State laws. (P.A. 258 of 1974, Section 748(3); P.A. 368 of 1978; 42 CFR Parts 160 and 164 (HIPAA); P.A. 488 of 1989). CMHA-CEI will not condition treatment, payment, or program eligibility on the signing of this authorization.

Please return completed form to:

CMHA-CEI's Compliance Office

812 E. Jolly Rd Ste. 108, Lansing, MI 48910

Email: compliance@ceicmh.org

CMHA-CEI ROI (Rev. 2/26) Community Mental Health Services Program