Please note: Please complete for any providers that are currently working with the family. This may include Therapist, Psychiatrist, Primary Care Doctor, DCP&P, Probation Officer, School District/Teacher, etc. This authorization can be used for family members or close friends that could be of benefit to the team.
If you need more than 4 copies of this form, please inform your Care Manager.
I authorize FACT to disclose or obtain the following protected health information, including information about mental health treatment to/from:
Information about diagnosis or treatment for alcohol/substance may be disclosed as follows:
This authorization can be revoked at any time and expires one year after signing.
The confidentiality of the information disclosed is protected by Federal Law. Federal regulations (42 CFR part 2) prohibit making any further disclosure of this information without the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. Photocopy of this form is as effective as the original.