Authorization to Use or Disclose Protected Health Information Patient Name: ____________________________DOB: ____________[CT1] Phone: ______________________ I hereby request and authorize: Provider or Practice Name: __________________________________ Phone: ______________________ Address: _______________________________________________________________________________ to disclose the above named patient’s protected health information as described below to Bethany’s Butterflies Foundation at [insert email / fax / other secure method for provider to send information to Bethany’s Butterflies], for purposes of determining my eligibility and/or receiving financial support and other services offered by Bethany’s Butterflies. The type of information to be disclosed is as follows (information will be limited to the last 3 years unless otherwise requested): ÿ Diagnosis and Related Dates and Details ÿ Treatment Information ÿ Other: [CT2] ________________________________________________________________________________ ÿ I DO ÿ I DO NOT Authorize the release of information related to mental health treatment records, substance abuse (drug and/or alcohol) treatment records, or HIV/AIDS-related information. [Note: The release of psychotherapy notes requires a separate authorization.][CT3] I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing. I understand that such a revocation will not apply to information that has already used or disclosed in reliance on this authorization. Unless otherwise revoked or specific expiration indicated below, this authorization will expire 3 years from the date signed. Specific expiration indicated: _________________________________________ I understand that authorizing the disclosure of this protected health information is voluntary and I need not sign this form in order to receive treatment or services from my provider; however, unless certain information is provided to Bethany’s Butterflies Foundation, I may not be able to participate in their programs or services. I understand that once my protected health information is disclosed pursuant to this authorization, the information is subject to potential re-disclosure by the recipient and may no longer be protected by federal privacy laws. I further understand that I will receive a signed copy of this authorization.
Signature of Patient/Guardian/Legal Representative Date
Name of Guardian or Legal Representative (if applicable) Relationship to Patient
[CT1][CT1]While limiting the sensitivity of PHI collected for this purpose (i.e., remove DOB if not needed), add a field to capture whatever data point would be necessary to authenticate you have the correct patient.
[CT2]We need to [CT2]update this list as necessary to best reflect what types of information you will need