AUTHORIZATION FORM FOR THE USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION
This form is designed to help us provide the best coordination possible. Please enter as completely as you can.
If you have any questions, contact your BHPMW Care Coordinator directly or call our main line at 508-283-5110. Thank you.
Person Served Address
Person Served Phone Number
By signing this authorization, I authorize the Behavioral Health Partners of Metrowest (BHPMW) Referral Line to
Obtain my PHI from
Disclose my PHI to
Please select all that may be applicable
Protected Health Information (PHI) includes information collected from me or created by the above Providers, or information received by the above Providers from another health care provider, a health plan, my employer or other covered entity subject to the HIPAA regulations. Health information may relate to my past, present or future physical or mental health or condition, the provision of my health care, or payment for my health care services and will be used for the purposes of care coordination.
Substance use information including my past, present or future substance use related diagnosis or condition, the provision of substance use related care, or payment for substance use related services. I further understand that Behavioral Health Partners MetroWest and its employees are prohibited from disclosing information about treatment for alcohol or drug abuse without my specific written authorization unless a disclosure is otherwise authorized by federal SAMHSA regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records (42 CFR, Part 2). This information will be disclosed for the purposes of care coordination.
Information regarding AIDS, ARC or HIV including, for example, a test for the presence of HIV antibodies, antigens, regardless of whether (i) this test is ordered, performed or reported, and (ii) the test results are positive or negative.
Information regarding the results of a genetic test.
My PHI will be obtained or disclosed through
Telephone communication only
Both written and telephone communications
The PHI requested covers the period of initial contact until you are satisfactorily connected to services and includes the following
Behavioral Health Referral Document
Social Services Referral Document
Other (see box below)
This Authorization expires when you are satisfactorily connected to services or in the event that you choose to revoke it.
I understand that Behavioral Health Partners MetroWest and its employees cannot guarantee that PHI disclosed to the above indicated Person/Organization will not be re-disclosed to a third party. The Person/Organization may not be subject to federal laws governing privacy of health information. However, if the disclosure consists of treatment information about a person served in an alcohol or drug abuse program, the Person/Organization is prohibited under federal law from making any further disclosure of such information unless further disclosure is expressly permitted by written consent of the person served or as otherwise permitted under federal law governing Confidentiality of Alcohol and Drug Abuse Patient Records (42 CFR, Part 2).
AUTHORIZATION TO COMMUNICATE BY EMAIL, INSTANT MESSAGING, OR TEXT MESSAGING
Note: By signing below, you agree that Behavioral Health Partners MetroWest and the Behavioral Health Partners MetroWest staff who provide services to you can send email and/or SMS text messages that may not be private or secure to you and/or the third party that you name below. This authorization is for the transmission of Protected Health Information (PHI), only. Personally Identifiable Information (PII) cannot be transmitted by unsecured methods by regulation. Authorization
I do not authorize the unsecured communication of my PHI
I understand that this unsecured communication may contain my personal health information, including but not limited to my diagnosis, medications, appointment dates and times, my reasons for seeking support, and other such sensitive or confidential information relating to the services I receive at Behavioral Health Partners MetroWest. I understand that my personal health information is being sent by email or text messaging through a connection that may not be secure or encrypted. I understand that because I am authorizing my PHI to be sent by email and/or SMS/text messaging, which is not a secure method of communication, my confidentiality with respect to such communications cannot be ensured. I have discussed the risks with my Behavioral Health Partners MetroWest provider and all of my questions have been answered to my satisfaction.
I understand that I may revoke this authorization at any time by verbal or written notification to staff at the Behavioral Health Partners MetroWest. I understand that written notification of revocation can be mailed to the Behavioral Health Partners MetroWest, 1881 Worcester Road, Framingham, MA 01701. I further understand that it is possible for such communications to be re-disclosed by the Third Party and therefore such communications may no longer be protected, even after I revoke my authorization.
This authorization is not being required by Behavioral Health Partners MetroWest as a condition for receiving services, and is not intended to constitute a waiver of my rights that cannot by law be waived. I understand that I may refuse to sign this Authorization and that my refusal to sign will not affect my ability to obtain service from Behavioral Health Partners MetroWest.
Please note there are some limits to confidentiality according to Massachusetts State Regulations. Behavioral Health Partners MetroWest staff may be required to disclose information or records without prior written consent from the person receiving services in the following situations: (i) the person’s behavior creates a clear and present danger of harm to him/herself or others and/or (ii) in the event of suspected abuse or neglect of a child, or a disabled or elderly person.
I have read and understand the terms of this Authorization. I have had an opportunity to ask questions about the use or disclosure of my health information.
I authorize the content of this form.
Please select one
I am 18 years of age or older and am my own legal guardian
I am the legal guardian of the person served
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