Download CURRY HEALTH CENTER Counseling Services THE UNIVERSITY OF MONTANA-Missoula

Phone: 406-243-4711
CURRY HEALTH CENTER
Counseling Services
THE UNIVERSITY OF MONTANA-Missoula
634 Eddy Avenue
Missoula, MT 59812
FAX: 406-243-6963
RELEASE OF INFORMATION AUTHORIZATION
Client Name _______________________________________________
UM Student ID:___________________________
Date of Birth ________________________
Address ____________________________________________________
Phone ___________________________________
____________________________________________________
I authorize ___________________________________ at Counseling Services - UM Curry Health Center to:
Disclose information to:
Receive information from:
Name:
Name:
Agency name:
Agency name:
Address:
Address:
Phone:
Fax:
Phone:
Fax:
Information in my counseling record as directed below:
Psychiatric/Psychological/Counseling Progress Notes
Chemical Dependency Assessment and Treatment Notes
Psychological Test reports (i.e., ADHD report, etc)
Other requests or limitations (please specify)
Personal Information Form(s)
_____________________________________________________
Form in which information should be released:
_________Verbal
__________ Written
The information to be disclosed will be used for the following purpose: _________________________________
Only counseling records initiated by and maintained at Counseling Services at the Curry Health Center (UM-Missoula) are included in this release. This release
does not cover Curry Health Center medical records. If medical records are required, a separate medical release of information must be submitted to the medical records
department of the Curry Health Center.
I understand:
1. Authorizing the disclosure of this information is voluntary.
2. I can refuse to sign this authorization.
3. I need not sign this form in order to assure treatment.
4. A written request withdrawing this authorization may be submitted at any time (except to the extent that action has been taken in reliance upon it) to
Counseling Services at the address listed above.
5. Any disclosure of information carries with it the potential for an unauthorized redisclosure, and the information may no longer be protected by federal
confidentiality rules.
6. The information in my counseling record may contain protected information relating to sexually transmitted disease, acquired immunodeficiency syndrome
(AIDS), human immunodeficiency virus (HIV), and/or treatment for substance abuse.
Regarding HIV/AIDS/STD information, I give consent to release this information. (client initials)_____________
Regarding information on drug and/or alcohol use, I give consent to release this information. (client initials)____________
Authorization will expire in 6 months unless otherwise specified.
Expiration Date:
Client Signature (if over 18) ____________________________________________________
Date ____________________
Legal Representative/Guardian (if under 18) ___________________________________ Date ____________________
Relationship to Patient _________________________________________
Office use only:
Information released by:____________________________________________________________________ Date:__________________________
 Mailed
 Faxed
 Picked up
 Phone contact/conversation
TO THE RECEIVING AGENCY/FACILITY/PERSON:
This information has been disclosed to you from confidential records, which may be protected by federal and/or state law. If the records are so protected, Federal Regulation (42 CFR, Part 2)
prohibits you from making any further disclosure of this information unless disclosure is expressly permitted by the written consent of the person to whom it pertains, or as otherwise permitted
by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally
investigate or prosecute any alcohol or drug abuse client.
J:\__CHC Citrix_folder_structure\CHC CAPS\_CHC CAPS Admin Support\FORMS\Release of Info-CAPS.doc