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.  TREATMENT IS NOT CONTINGENT UPON SIGNING THIS AUTHORIZATION.  IF INFORMATION DISCLOSED TO THE ABOVE SPECIFIED PARTY IS REDISCLOSED BY SAID PARTY, IT IS NO LONGER PROTECTED BY PBS MENTAL HEALTH ASSOCIATES.

_______________________________________

    ________________________________________

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.