UPPER
UPPERBAY
BAYCOUNSELING
COUNSELINGAND
& SUPPORT
SUPPORTSERVICES,
SERVICES,INC.
INC.
Authorization for Release of Information
To be
be Valid,
Valid, this
this form
form must
must be
((To
be filled
filled out
out completely.)
completely.)
Client’s Name
Client’s
Name ____________________________________________
____________________________________________
AKA:______________________________________
Date of
Date
of Birth
Birth________________________________
________________________________Social
Social
Security
Security
Number
Number
________________________________________
(last four digits) XXX-XXI, ______________________________________________ do hereby authorize Upper Bay Counseling & Support Services, Inc.
Please initial
appropriate
line(s)
Please
initial
all appropriate
line(s)
_____ To Release Information To:
_____ To Obtain Information From:
_____
Verbal
Communication
_____ Information
Ongoing Interagency
_____ To
Release
Information
To:
_____ To Obtain
From: Communication
_____ Ongoing Communication
_____________________________________________________________________________________________
______________________________________________________________________________________________________
(Name of
(Name
of Person)
Person)
(Organization)
(Organization)
__________________________________________________________________________________________________________________
(Street Address)
(City)
(State)
(Zip Code)
(Street
Address)
(City)
(State)
(Zip
Code)
Method of Disclosure: ____ Verbal Communication
_____ Photo Copy
___ Electronic copy via CD
I understand that this information includes treatment for behavioral, mental and/or physical illness, counselIing
understand
that this
for behavioral, mentaldisease
and/or physical
illness,
or treatment
for information
drug and/orincludes
alcoholtreatment
abuse, infectious/contagious
including,
but counseling
not limitedorto,
treatment
for
drug
and/or
alcohol
abuse,
infectious/contagious
disease
including,
but
not
limited
to,
HIV/AIDS
or tests
HIV/AIDS or tests for HIV or AIDS, and developmental disabilities.
for HIV or AIDS, and developmental disabilities.
Specific information not to be disclosed: __________________________________________________________
Specific information not to be disclosed: __________________________________________________________
The specific type of information to be disclosed includes: (Initial all items to be released)
The specific type of information to be disclosed includes: (Initial all items to be released)
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
Discharge Summary
_____ Initial Assessment
_____ PRP Contact Notes: Date(s) ________________
Discharge Summary
_____ Initial Assessment (Diagnostic Impression & Psychosocial Assessment)
Physical Exam & History _____ Medication Orders
_____ School/Educational Records
Physical Exam & History _____ Medication Orders
_____ School/Educational Records
Psychological Testing
_____ Aftercare Plan
_____ Lab/Testing Report
Psychological Testing
_____ Aftercare Plan
_____ Lab/Testing Report
Referral: _________________________________________________________________________________________
Referral: _________________________________________________________________________________________
Individual Treatment Plan: Date(s) ____________________
_____ Individual Rehab Plan: Date(s) ______________
Individual Treatment & Rehab Plan (includes complete diagnosis) Dates:_____________________________________
_____
_____
_____
_____
Psychiatric Progress Note(s): Date(s)__________________________________________________________________
Prescriber’s Progress Note(s): Date(s)________________________________________________________________
Other (Be Specific):_________________________________________________________________________________
Other (Be Specific):_________________________________________________________________________________
The purpose of this disclosure to/for: (initial all that apply)
The
purpose
of this&disclosure
(initial_____
all that
apply) of Services
_____
Evaluation
Treatmentto/for:
Planning
Coordination
_____ Evaluation & Treatment Planning
_____ Assist with Legal Issues
_____ Assist with Legal Issues
_____ Inform Family Member
_____ Inform Family Member
_____
_____
_____
_____
_____
Coordination of Services
Disability Claim
Disability Claim
Inform Employer
Inform Employer
_____ At My Request
_____ Job Recommendations
_____ Job Recommendations
_____ Other ___________________________
_____ Other ___________________________
I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this
Iform
understand
authorizing
the disclosure
of this
health
information
voluntary. carries
I can refuse
sign
this authorization.
I need not
sign this
in orderthat
to receive
treatment.
I understand
that
any disclosure
ofisinformation
with ittothe
potential
for an unauthorized
redisclosure
form
in information
order to receive
I understand
that any disclosure
and the
maytreatment.
not be protected
by confidentiality
rules. of information carries with it the potential for an unauthorized redisclosure
and the information may not be protected by confidentiality rules.
I understand that I may revoke this authorization in writing at any time. Otherwise this authorization is valid for until one year after date of
I understand that I may revoke this authorization in writing at any time. Otherwise, this authorization is valid for one year from the date of signature,
signature or ___________________________________________________________
or Discharge (Specification
from UBCSS -or________________________________________________________(Specification
of date, event, or condition upon
of date/event,
or condition upon which consent expires)
which consent expires) (whichever comes first)
Date: ______________________________
Date: ______________________________
Signature: ________________________________________________________
Signature: _______________________________________________________
Witness: ___________________________
Witness: ___________________________
___________________________________________________________
___________________________________________________________
(If Signed by Legal Representative, Relationship to Patient)
(If Signed by Legal Representative, Relationship to Patient)
Any individual or agency receiving this information is prohibited from making any further disclosure of this information without the specific written consent of the person to whom it
Any
individual
receiving
this information
is prohibited
from consistent
making any
further
disclosure
information
without
specificwhereby
written consent
of the person
it
pertains
(or thator
ofagency
the their
legal representative),
except
in those cases
with
Maryland
Stateoforthis
Federal
Law, statute,
or the
regulation
this information
mustto
bewhom
produced
pertains
(or that
of the their legal representative), except in those cases consistent with Maryland State or Federal Law, statute, or regulation whereby this information must be produced
or other wise
examined.
or other
examined.
wise Booth
Street Office
 Route 40 Office
 Havre de Grace Office
 Delaware Adoption & Counseling

Booth996-5104
Street Office
(410)
(410)
Fax: 996-5104
(410) 996-5197
Fax: (410) 392-8048
Rev. April, 2005
(410) 620-7161 Route 40 Office
(410) 939-8744
(410) 620-7161Fax: (410) 939-8748
Fax: (410) 620-7168
Fax: (410) 620-7168
de Grace Office
(302)Havre
368-8417
Fax:(410)
(302)939-8744
368-1197
Fax: (410) 939-8748
Rev. October, 2013