Consent for the Release of Confidential Information Form
I authorize Graceland Psychiatry, DISCLOSE TO/OBTAIN FROM Maryland Medical Assistance Program or Medicaid (Optum and all MCOS), Mental Health Management Agency (MHMA) and Local Addiction Authority (LAA), Outpatient Centers, Medication Assisted Treatment Physicians, and Any Physician listed as a CURRENT PRESCRIBER under my personal information.
I understand that my records are protected under the Federal regulations governing Confidentiality of Mental Health Records, 42 C.F.R. Part 2, and that any information that identifies me as a patient in a Mental Health program cannot be disclosed without my written consent except in limited circumstances as provided for in these regulations.
I understand that my records are also currently protected under the Federal privacy regulations within the Health Insurance Portability and Accountability Act (HIPAA), 45 C.F.R. Parts 160 & 164. I understand that my health information specified above will be disclosed pursuant to this authorization and that the recipient of the information may re-disclose the information and it may no longer be protected by the HIPAA privacy law. The Federal regulations governing Confidentiality of Mental Health Re Records, 42 C.F.R. Part 2, noted above, however, will continue to protect the confidentiality of information that identifies me as a patient in a Mental Health program from re-disclosure.
I understand that the covered entity seeking this authorization is not conditioning treatment, payment, enrollment, or eligibility for benefits on whether I sign the authorization. I also understand that I may revoke this authorization at any time except to the extent that action has been taken in reliance on it, and that in any event, this authorization expires automatically one year minus a day from the date that it is signed.
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