Bethany's Butterflies Foundation
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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

 

  • Home
  • About Us
    • Bethany's Story
    • Board of Directors
  • Apply For Support
    • Applications/Forms
  • Events
  • Sponsorship
  • Kaleidoscope
  • Volunteer
  • Donate
  • Shop
  • Contact