Shorehaven Behavioral Health, Inc.
Complete a separate copy of this form for each person or institution which has records on you or to whom we should speak.
I, ___________________________________, consent to the disclosure of the specific information listed below, by written, faxed, electronic, or verbal communication,
by/to Shorehaven Behavioral Health, Inc., 3900 W. Brown Deer, Suite 200, Brown Deer, WI 53209,
Purpose: The purpose or need for this disclosure is to help me(us) by:
( ) Other Health Care Operations: Medical, educational, legal,
( ) Other Information:________________________________________________________
I understand I may request a Shorehaven privacy policies notice. I understand I may restrict the information to be released and its use. I am aware of the information to be released and agree to its disclosure. I authorize the disclosure of the following specific information:
( ) Psychiatric, social, psychological, & allied health evaluations
( ) Medical history, current medical conditions, medications
( ) BMCW Case Plan
( ) Diagnosis, prognosis, & treatment for physical and/or emotional disorders, including alcohol or drug abuse
( ) Other:_____________________________
Revocation: This consent may be revoked by written notice at any time except to the extent the provider of information has already acted upon it. In any case, consent expires twelve (15) months from the date below, or earlier if noted here:___/___/__.
Staff: HIPAA, 45 CFR Parts 160 and 164 requires documentation of the history of all releases in a format which could be given to the patient upon request. Document the release on a separate progress note page. (Rev 5/25/06)