Release of information
Authorization of release of mental health and substance use record(s).
I authorize Bend Health to use or disclose information from child/teen’s mental health and substance use record, which may include information about psychiatric diagnosis and treatment and substance use issues
- I understand that, unless withdrawn, this authorization will expire 365 days from the consent date. A photocopy or copy of this consent will be considered as valid as the original.
- I understand that I may revoke this authorization at any time by notifying Bend Health at firstname.lastname@example.org, in writing, and this authorization will cease to be effective on the date notified except to the extent action has already been taken in reliance upon it.
- I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer be protected by Federal privacy regulations. However, other state or federal law may prohibit the recipient from disclosing specially protected information, such as substance abuse treatment information and mental health information.
- I understand that my refusal to sign this Authorization will not jeopardize my child/teen’s right to obtain present or future treatment for psychiatric disabilities except where disclosure of the information is necessary for the treatment.
- My health care and payment for my child/teen’s health care at Bend Health will not be affected if I do not sign this form.
- I understand that I can request a copy of this form after I consent to it.