P.B.S. MENTAL HEALTH ASSOCIATES, P.C.

An Affiliate of UPMC Behavioral Health Network

901 EAST BRADY STREET

SUITE 103

BUTLER, PENNSYLVANIA  16001

(724) 282-1627

PATIENT NAME: __________________________________________________________________

ADDRESS: _______________________________________________________________________

DATE OF BIRTH: ____________________ SOCIAL SECURITY: ___________________________

I, __________________________________, HEREBY AUTHORIZE _________________________

_________________________________________________________________________________

TO OBTAIN FROM/RELEASE TO AND COMMUNICATE WITH: __________________________

_________________________________________________________________________________

REGARDING INFORMATION FROM MY RECORDS, OR MY CHILD'S RECORDS, INCLUDING:

_____PSYCHOLOGICAL EVALUATION	_____ABSTRACT
_____PSYCHIATRIC EVALUATION	_____PSYCHOSOCIAL HISTORY
_____SOCIAL WORK REPORTS	_____TREATMENT/AFTERCARE PLAN
_____DIAGNOSTIC OPINION	_____HIV SCREENING
_____MEDICAL HISTORY/EVALUATION	_____URINE DRUG SCREENS
_____DISCHARGE SUMMARY	_____OTHER_____________________
_____CLINICAL AND/OR LAB TEST	___________________________
_____DRUG/ALCOHOL DIAGNOSIS/TREATMENT	___________________________

FOR THE PURPOSE OF ___________________________________________________________

THIS CONSENT WILL BEGIN ON THE DATE OF THIS AUTHORIZATION AND WILL EXPIRE ONE YEAR LATER, ON _______________.  I, THE UNDERSIGNED, HEREBY ACKNOWLEDGE THAT I HAVE READ THIS AUTHORIZATION PRIOR TO ITS EXECUTION AND FULLY UNDERSTAND THE NATURE OF THIS RELEASE.  I UNDERSTAND THAT I CAN REVOKE OR CANCEL THIS AUTHORIZATION AT ANY TIME BY SENDING A LETTER TO THE PRIVACY OFFICER.  IF I DO THIS, IT WILL PREVENT ANY RELEASES AFTER THE DATE IT IS RECEIVED BUT CANNOT CHANGE THE FACT THAT SOME INFORMATION WAS SENT OR SHARED BEFORE THAT DATE.

_______________________________________	________________________________________
WITNESS/DATE	SIGNATURE/DATE (14 YRS AND OLDER)
	________________________________________
	SIGNATURE/DATE (PARENT/GUARDIAN)

THIS INFORMATION IS FROM RECORDS WHOSE CONFIDENTIALITY IS PROTECTED BY FEDERAL LAW (PL 92-202).  FEDERAL REGULATIONS PROHIBIT MAKING ANY FURTHER DISCLOSURE WITHOUT THE SPECIFIC WRITTEN CONSENT OF THE PERSON TO WHOM IT PERTAINS, OR AS OTHERWISE PERMITTED BY SUCH REGULATION.  A GENERAL AUTHORIZATION FOR THE RELEASE OF MEDICAL OR OTHER INFORMATION IS NOT SUFFICIENT.