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The document is an authorization form from a Behavioral Health Clinic that allows clients to request or release their protected health information (PHI). It outlines the necessary details for the request, including client identification, purpose of the information request, and methods of disclosure. The document emphasizes confidentiality and legal restrictions on sharing PHI, particularly regarding substance use records. Additionally, it includes guidelines for email communication and consent for involving other adults in treatment discussions.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the Client Name and Date of Birth in the designated fields. This information is crucial for identifying the individual whose records are being requested.
Select whether you want to release or request protected health information (PHI) by checking the appropriate box.
Fill in the details of where to send the information, including Name, Agency (if applicable), Address, Phone, and Fax. If email is your preferred method of disclosure, provide an email address.
Indicate the purpose for requesting this information by selecting one of the options provided, such as Further Medical Care or Insurance Eligibility/Benefits.
If applicable, ensure that a minor's signature is included for substance abuse records.
Review all entered information for accuracy before signing and dating the form at the bottom.

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An online form is an electronic application in which data is entered by the person filling it out for recording and further processing via predefined data fields. Such electronic forms can be found, for example, on websites or as attachments in e-mails.