KARNER PSYCHOLOGICAL ASSOCIATES
AUTHORIZATION TO USE AND DISCLOSE
PROTECTED HEALTH INFORMATION
1. I am completing this form to authorize and allow the use and sharing of protected Health information about: ___________________________________________________
Printed Name
Date
of Birth
2. I hereby authorize Karner Psychological Associates or it’s designated mental health professional to use or disclose the following information (Check all that apply):
□ Treatment records for psychological, psychiatric or emotional illness.
□ Admission or discharge summaries.
□ Psychological or Social Work evaluation(s), reports, assessments, treatment notes, summaries, or other documents with diagnoses, prognoses, recommendations, or testing records, and behavioral observations or checklists completed by any KPA therapist or psychologist, or the patient, or similar documents.
□ Treatment, recovery, rehabilitation, aftercare plans or other similar plans.
□ Social, family, educational and
vocational histories.
□ Progress or “case” notes, or similar notes.
□ Information about how the patient’s condition(s)
affects or has affected his or her ability to work, and complete tasks or
activities of daily living.
□ Billing records.
□ Academic and educational records, including achievement and other test results, reports of teachers’ observations, and other school or special education documents.
□ HIV-related information and drug and alcohol
information contained in KPA records will be released under this
authorization unless indicated here. □ Do not release these records.
□ Complete copy of the KPA record and the folder in which it was kept.
□ Other:_________________________________________________________
3. Dates of care included:
From: _________________ to
_________________
(This will expire in one year)
4. I authorize the use/disclosure of the information noted
above to from
______________________________________ and/or _______________________________
Name of person/organization
Name
of person/organization
5. The information will be used/disclosed for the following
purpose(s):
__________________________________________________________________________
___________________________________________________________________________
6. I understand that this Authorization will be valid and in effect until _________________.
I further understand that after that date or event, no more of my information can be used or disclosed to the person or organization unless I sign a new Authorization like this one.
7. I
understand that I can revoke or cancel this Authorization by sending a letter
to the KPA Privacy Officer. If I
do so, it will prevent any disclosures after the date it is received but cannot
change the fact that some information may have been disclosed or shared before
that date.
8. I understand that I do not have to sign this Authorization
and that my refusal to sign will not affect my abilities to obtain treatment
from KPA.
9. I understand that I may inspect and have a copy of the information described in this Authorization and that there may be a cost for this copy or other services associated with producing my copy. □ Does not apply.
10. I understand
that if the person or entity that receives the authorized information from KPA
is not a health care provider or health insurance plan covered by federal
privacy regulations (HIPPA), the information described above may be
re-disclosed and is no longer protected by HIPPA regulations.
I affirm that
everything in this Authorization Form that was not clear to me has been
explained and I believe I now understand all of its provisions.
______________________________________________ __________________________
Signature of patient or
his/her personal representative
Date
______________________________________________ __________________________
Printed name of patient or
personal representative
Relationship
to patient
___________________________________________________________________________
Description of personal representative’s authority
□ I acknowledge that I have received a copy of this signed, completed form.
I, a mental health professional, representing Karner
Psychological Associates. have discussed the issues
above with the patient and/or his/her personal representative. My observations of his/her behavior and
responses give me no reason to believe that this person is not fully competent
to give informed and willing consent.
____________________________ _______________________________ ____________
Signature of KPA professional
Printed
name of professional
Date
Revised