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CONSENT FOR RELEASE

OF INFORMATION

Patient’s Name (Last, First, M.L)

 

DOCS Id.                             Data of Birth

 

 

See Reverse Side /or Instructions

Facility Name                        Unit/Ward No.

Part I — Consent To Release Information

Essence or Nature of Information to be Disclosed

Purpose or Need for Information

 

From: Name, Address and Title of Person/ Organization/Facility/

Program Disclosing Information

To: Name, Address and Title of Person/Organization/Facility/

Program to Which Disclosure Is To Be Made

A.        I Hereby Authorize the One-time Release of the Above Information to the Person/Organization/Facility/ Program Identified Above. I Understand that the Information to be Released is Confidential and Protected from Disclosure. I also Understand that I Have the Right to Cancel My Permission to Release Information at any Time. 

 

 

My Consent to Release Information Will Expire When Acted Upon or 90 Days From this Date, Whichever Occurs First.

Signature of Patient/Person Acting For Patient

Relationship

Date Signed

Signature of Witness

Title

Date Signed

 

B.       I Hereby Authorize the Periodic Release of the Above Information to the Person/Organization/Facility/Program Identified Above

as Often as Necessary to Plan For/Provide Care and Treatment. I Understand that the Information to be Released is Confiden?

tial and Protected from Disclosure. I also Understand that I Have the Right to Cancel My Permission to Release Information At

Any Time.

 

My Consent to Release Information to the Person/Organization/Facility/Program Identified Above Will Expire When I am no lon?

ger Receiving Services from such Person/Organization/Facility/Program, or One Year from this Date, Whichever Occurs First

Signature of Patient/Person Acting For Patient

Relationship

Date Signed

Signature of Witness

Title

Date Signed

 

Record of Information Released

Signature of Staff Person Releasing Information

Title

Date Released

 


Form DMH 11 (B-57) Page 2

 

Part II – Cancellation/Refusal To Release Information

q         I Hereby Cancel My permission to Release Information Indicated in Part I. to the Person/Organization/Facility/ Program whose Name and Address is:

q        I Hereby Refuse to Authorize the Release of Information Indicated in Part I. to the Person/Organization/Facility Program whose Name and Address is:

 

 

 

 

 

 

 

 

Signature of Patient/Person Acting For Patient

 

Relationship

Date Signed

Signature of Witness

Title

Date Signed

 

(Use this space if additional mom is needed to complete any of the items on the reverse side)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

-INSTRUCTIONS-

1.         Patient Signs A...If the Release of Information is for a Single Event

2.         Patient Signs B...If Information is to be Released Periodically during an episode of treatment

3.         If the patient is under 18 years of age only the responsible parent, relative or guardian must sign.

Exception: if patient is a Voluntary Admission on own application, at least 16 years of age but under 18 years of age only the patient must sign.

99999.053 #316942

 

Form based on information provided by Prisoners’ Legal Services of New York

 

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