Release of Mental Health Information form - University Health Center 2025

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HIPAA permits health care providers to disclose to other health providers any protected health information (PHI) contained in the medical record about an individual for treatment, case management, and coordination of care and, with few exceptions, treats mental health information the same as other health information.
How do I fill out a HIPAA release form? Provide instructions. Name the patient and individual authorized to use or disclose their PHI. Describe the information. Specify recipients. Specify the purpose of disclosure. Specify the time period. Detail their revocation rights. Obtain the patients signature.
Only one LOA is issued for each provider for up to 12 months of services. A provider needs only one letter for all months for which the client received medical services. If an LOA is lost, every effort must be made to locate the original.
The patient may enter the date he/she wants the authorization to expire. The patient may enter an expiration event. The patient may enter a date range of information to be shared. If no expiration date is specified, this authorization is good for 12 months from the date signed in Section IX.
The duration of a release of information authorization can vary. Typically, the form will specify an expiration date or event. For instance, it may be valid for a specific period (e.g., six months or one year) or until a particular event occurs (e.g., the conclusion of a treatment episode).

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Releasing patient records without proper authorization violates HIPAA regulations. The form must have a valid signature, date, and purpose of the release of the request. If the patients information is incorrect or incomplete, it may lead to the release of the wrong medical records.
Theres no statutory time period within which a release must expire. However, under HIPAA, an authorization to release medical information must include a cutoff date or event that relates to whos authorizing the release and why the information is being disclosed.
What is a mental health release of information form? A mental health release of information form outlines who has access to your clients medical records and under what circumstances they have access. This form is signed and acknowledged by your client.

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