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AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION
Case ID
Client First Name:
Client Last Name
Date of Birth
Last 4 of SSN
1. Authorization is hereby granted to UK Health and Wellness Mental Health Therapists to exchange relevant clinical information with:
UKHC Outpatient Psychiatry
UKHC Team Blue
UK College of Education: Community Mental Health Clinic
UK Human Resources
UK Individual, Relational, and Financial Therapy (I-RAFT) Clinic
UK Jesse G. Harris, Jr. Psychological Service Center
UK Office of Institutional Equity and Equal Opportunity
UK Violence Intervention and Prevention (VIP) Center
Health Insurance Provider
Other Person/Organization
Select information you are authorizing to share with
UKHC Outpatient Psychiatry:
Access my EPIC chart to complete referral order
Exchange clinical information
Select information you are authorizing to share with
UKHC Team Blue
:
Access my EPIC chart to complete referral order
Exchange clinical information
Name of Hospital and/or Provider
Name of Person(s) in HR
Health Insurance Provider
Other Person/Organization, Address, Phone:
2. I authorize the sharing of the following specially protected records:
Diagnosis, treatment, assessment, and/or consultation for mental health or psychiatric disorders
Diagnosis or treatment of drug and/or alcohol abuse
Diagnosis or treatment of AIDS and/or HIV
Genetic testing, counseling, and education
Other
List Other Record(s):
3.
Release records from the following dates
:
All Dates of Treatment
Specific Dates of Treatment
From
To:
4. For the following purpose
(check all that apply):
Permission to discuss care
For another provider
Personal Use
Letters/Forms
Other
Other Purpose:
5. This authorization expires on:
If no date is listed, the authorization will expire 90 days from this date.
I have read and understand this information. I am the client or am authorized to act on behalf of the client to sign this document authorizing the use or disclosure of protected health information under the above stated terms
Please check here if client is unable to sign
Yes
As client is unable to sign, secure consent of legal representative and indicate reason.
Minor
Incompetent
Deceased
Other
Other Reason
Contact Information
859-257-9355
employeementalhealth@uky.edu