I, DOB: hereby give my permission to Mental Health Services of Maryland, LLC, to release or request, from a third party, information contained in my medical record. I understand that my medical record may contain sensitive information classified as privileged and confidential which cannot be released  without  my  consent. In addition, I understand that those records will not be released to entities other than those designated by myself or my personal representative or otherwise provided in federal law. This information will be released/requested upon request to the following: 

To:
Full Name:
Email:
Phone:
Address:

The type of information to be disclosed/requested is as follows: 

To Be Released from Mental Health Services of Maryland, LLC 

Treatment PlansProgress NotesHealth/Medical Records (if applicable)Letter(s) of ProgressPsychological/Psychiatric EvaluationsBio Psychosocial Assessment (if applicable)Court DocumentsVerbal CommunicationOther

Other (Specify):

Check each box to agree to each term.

In the case of notes documenting or analyzing the contents of conversation during a private counseling session (“process notes”), such records may be protected from disclosure under the HIPAA Privacy Rule).
I understand that I have the right to withdraw my authorization at any time except to the extent that action has already been taken pursuant to the authorization. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to Mental Health Services of Maryland, LLC.

I understand that authorizing the disclosure of this health information is voluntary, I can refuse to sign, and Mental Health Services of Maryland, LLC will not base my treatment or payment whether or not I provide authorization for the requested use or disclosure. I understand that I may inspect or copy the information to be disclosed, as provided in CFR164.524 (with reasonable charge).

I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient of the information and is no longer protected by federal confidentiality laws or Mental Health Services of Maryland, LLC. Mental Health Services of Maryland, LLC will not be held liable for information disclosed to another party per the client’s request.

I understand that Mental Health Services of Maryland, LLC will release only the minimum amount of information necessary to fulfill a request. This authorization shall expire when the client is discharged from the current episode of care (treatment has been completed, the client rejects/declines/drops out of treatment, is referred elsewhere, moves, or in the case of the client's death.) This agreement is subject to revocation in writing at any time.

Client Signature:

Date: