Form Mr 10 56 PDF Details

The MR 10 56 form is a critical document for individuals receiving treatment from Inova Comprehensive Addiction Treatment Services, located at 3300 Gallows Road, Falls Church, Virginia. It serves as an Authorization to Release Protected Health Information, enabling the treatment center to disclose a patient's health information to specified entities or individuals. The form captures essential data including the patient's full name, contact information, medical record number, and service dates, ensuring the precise identification and subsequent communication of health data. Patients authorize the release of various types of information such as admission details, diagnostic lab work, assessment and diagnosis outcomes, program participation, compliance with treatment recommendations, financial documentation, and results of substance use monitoring tests, among other vital records. The intended use of the disclosed information ranges from service coordination to legal and emergency contacts, highlighting the form's versatility in facilitating comprehensive care and support. Importantly, the form underscores the protected nature of the information under Federal confidentiality regulations (42 CFR Part 2), emphasizing the illegality of re-disclosure without explicit consent. It also outlines the patient's right to revoke consent at any stage, the automatic expiration of consent 90 days post-signature, and clarifies that Inova CATS cannot condition treatment on the signing of the authorization. This document embodies the complex interplay between patient confidentiality, the need for informed and integrated care, and the regulatory frameworks guiding the release of health information.

QuestionAnswer
Form NameForm Mr 10 56
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesinova authorization form, cats authorization release pdf, inova authorization release information, inova release health information form

Form Preview Example

AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION

Inova Comprehensive Addiction Treatment Services (CATS)

3300 Gallows Road, Falls Church, Virginia 22042

 

 

 

 

 

 

Central Accessrzoj) 776-7777

 

Fax (703) 776-7799

 

 

Patient

Full Name

 

 

 

 

 

Medical Record

#

 

Street

 

 

 

 

 

 

 

City

 

State

Zip

Telephone

Numbers: (home)

 

 

 

 

 

(cell)

 

 

 

Patient's

 

Date

of Birth

 

 

 

 

Dates

of Service

 

 

 

I,

 

 

 

 

 

 

 

authorize

Inova Comprehensive

Addiction

Treatment

Services

to release I disclose

the following information

TO:

 

 

 

 

 

Name or Person or Entity to

receive information

 

 

 

Relationship

to

Patient

 

Street

 

 

 

 

 

 

 

City

 

State

Zip

Telephone

Number

 

 

 

 

Fax Number

 

 

 

Information to be released I disclosed:

 

 

 

 

 

 

 

o Admission to

the program

 

 

 

 

 

o Diagnostic

lab work

 

o

Assessment

and Diagnosis

 

(Axis 1-5)

 

 

 

o Program

participation

 

o

Compliance

with treatment

 

recommendations

and referrals

 

o Financial

documentation

o

Results

of drug screens and

breathalyzer tests

 

 

 

o Treatment

plan goals

and objectives

o Progress towards accomplishing treatment plan goals and objectives

 

 

 

DOther

 

 

 

 

 

 

 

_

 

 

 

 

For the purpose of: o Service coordination

o Participation in family program

o Reports to probation officer or attorney

o Emergency

Contact

o

Completion of family interview

o

Other

_

I understand that my records are protected under Federal confidentiality regulations (42 CFR Part 2). Any person or entity receiving my information will be informed that re-disclosure is not permitted without my consent or otherwise permitted by the regulations. I also understand that I may revoke this consent at any time, except to the extent that action has been taken in reliance upon it. I understand that written notification is preferred, but not required to revoke this consent and should be forwarded to the address at the top of this form. I understand that in any event this consent automatically expires 90 days from the date of signature. This consent includes information placed in my record after the date of the signature below.

I understand that Inova Comprehensive Addiction Treatment Services (CATS) may not condition my treatment on my decision to sign this authorization.

Signature of Patient or Authorized

Representative

Date (Authorization

expires 90 days after signature)

Printed Name of Authorized

Representative

(as applicable)

Relationship to Patient

Addressograph

INOVA COMPREHENSIVE ADDICTION TREATMENT SERVICES

Authorization to Release Protected Health Information

MR-10-S6(REV 03/12)

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