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Ma authorization release

Massachusetts release information 2026

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The document is an authorization form from the Commonwealth of Massachusetts Department of Mental Health, allowing for the one-way release of mental health information to a specified person, facility, or agency. It outlines the necessary details for the release, including personal information of the individual authorizing the release, the purpose of the authorization, and rights regarding revocation. The form also includes provisions for specially authorized releases concerning sensitive information such as substance abuse and HIV status.

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Click ‘Get Form’ to open the Massachusetts Release Information document in the editor.
Begin by entering your name and any other names you may have used in the designated fields. This ensures accurate identification.
Fill in your address, phone number, social security number, and date of birth. These details are crucial for verifying your identity.
Specify the recipient of the information by filling out their name, address, and contact details. This is essential for directing the release appropriately.
Indicate the specific information you wish to be released by selecting from options like Entire Record or specific documents such as Evaluations or Progress Notes.
State the purpose for this authorization, choosing from options like 'Coordinate care' or 'Obtain insurance benefits.'
Sign and date the form at the bottom. If signed by a personal representative, include their authority type.

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2003	4.9 Satisfied (420 Votes)

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Does Massachusetts have a Freedom of Information Act?

Laws mandating the disclosure of public records have existed in the Commonwealth of Massachusetts since 1851. The federal Freedom of Information Act was signed into law in 1966 by President Lyndon B. Johnson.

What must a patient do to release information?

If requested by an individual, a covered entity must transmit an individuals PHI directly to another person or entity designated by the individual. The individuals request must be in writing, signed by the individual, and clearly identify the designated person or entity and where to send the PHI.

What is required for a release of information?

A HIPAA-compliant HIPAA release form must, at the very least, contain the following information: A description of the information that will be used/disclosed. The purpose for which the information will be disclosed. The name of the person or entity to whom the information will be disclosed.

What information is included on the release form?

Information Included on a Release Form A typical release form includes the following information: The name and contact information of the person granting the release. The name and contact information of the person or entity receiving the release. A description of the information or rights being released.

What is required before any information in a patient chart can be released?

In most other situations, the physician should not release information from the patients chart without the patients written permission. At the first patient encounter, the physician should have the patient sign an authorization to release information as necessary for the patients treatment.

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What does a release of information need to include?

Consent to Release Information The name of the person or entity authorized to make the request (usually the patient) The complete name of the person or entity to receive the protected health information (PHI) A specific description of the information to be used or disclosed, including the dates of service.

What are three reasons that information can be released without patient consent?

A covered entity is permitted, but not required, to use and disclose protected health information, without an individuals authorization, for the following purposes or situations: (1) To the Individual (unless required for access or accounting of disclosures); (2) Treatment, Payment, and Health Care Operations; (3)

Massachusetts release information 2026

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Got questions?

Does Massachusetts have a Freedom of Information Act?

What must a patient do to release information?

What is required for a release of information?

What information is included on the release form?

What is required before any information in a patient chart can be released?

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What does a release of information need to include?

What are three reasons that information can be released without patient consent?

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