Momentum-cares | RELEASE OF INFORMATION

Step 1 of 7

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Consumer Name:(Required)

First Last

SS#:(Required)

DOB:(Required)

MM slash DD slash YYYY

Email of Person Completing Form:(Required)

Types of Release:(Required)

Emergency Contact

Primary Care Physician

Mental Health Provider

School

Other

Revoke/ Refuse

EMERGENCY CONTACT

Release To:(Required)

First Last

Emergency Contact

Contact Number:(Required)

I, Voluntarily give my consent to authorize representatives of Momentum Cares and the addressee to exchange information as indicated below. This information is to be kept confidential and may not be released to any other agency or individual(s) without my signed consent. The purpose of this information exchange is to provide continuity of care and to assist the addressee and Momentum Cares in my treatment. In no way will information exchanged be used to discriminate against me or to deny me from receiving services at Momentum Cares.(Required)

First Last

Person giving permission.

Emergency Contact to Release:(Required)

Verbal Exchange between the above named entity and agency

Intake Assessment and Treatment Plan

Medication List

Quarterly Review

Transfer/Discharge Summary

Physical Examination Records (within one year of date signed)

Physician Recommendation for Community Rehabilitation Services

Other

None of the Above

Other:(Required)

Agency to Release:(Required)

Intake Assessment

Entitlement Information

Treatment Plans (ITP, ITRP and Review)

Psychiatric Assessment, Notes, Medication Log

Transfer/Discharge Summary

None of the Above

PRIMARY CARE

Practice/Practitioner Name:(Required)

Contact Number:(Required)

First Last

Person giving permission.

Practice/Practitioner to Release:(Required)

Verbal Exchange between the above named entity and agency

Intake Assessment and Treatment Plan

Medication List

Quarterly Review

Transfer/Discharge Summary

Physical Examination Records (within one year of date signed)

Physician Recommendation for Community Rehabilitation Services

Other

None of the Above

Other:(Required)

Agency to Release:(Required)

Intake Assessment

Entitlement Information

Treatment Plans (ITP, ITRP and Review)

Psychiatric Assessment, Notes, Medication Log

Transfer/Discharge Summary

None of the Above

MENTAL HEALTH PROVIDER

Practice/Practitioner Name:(Required)

Contact Number:(Required)

First Last

Person giving permission.

Practice/Practitioner to Release:(Required)

Verbal Exchange between the above named entity and agency

Intake Assessment and Treatment Plan

Medication List

Quarterly Review

Transfer/Discharge Summary

Physical Examination Records (within one year of date signed)

Physician Recommendation for Community Rehabilitation Services

Other

None of the Above

Other:(Required)

Agency to Release:(Required)

Intake Assessment

Entitlement Information

Treatment Plans (ITP, ITRP and Review)

Psychiatric Assessment, Notes, Medication Log

Transfer/Discharge Summary

None of the Above

SCHOOL

School Name:(Required)

Contact Number:(Required)

First Last

Person giving permission.

School to Release:(Required)

Verbal Exchange between the above named entity and agency

Intake Assessment and Treatment Plan

Medication List

Quarterly Review

Transfer/Discharge Summary

Physical Examination Records (within one year of date signed)

Physician Recommendation for Community Rehabilitation Services

Other

None of the Above

Other(Required)

Agency to Release:(Required)

Intake Assessment

Entitlement Information

Treatment Plans (ITP, ITRP and Review)

Psychiatric Assessment, Notes, Medication Log

Transfer/Discharge Summary

None of the Above

OTHER

Name/Agency:(Required)

Contact Number:(Required)

First Last

Person giving permission.

Named Entity to Release:(Required)

Verbal Exchange between the above named entity and agency

Intake Assessment and Treatment Plan

Medication List

Quarterly Review

Transfer/Discharge Summary

Physical Examination Records (within one year of date signed)

Physician Recommendation for Community Rehabilitation Services

Other

None of the Above

Other:(Required)

Agency to Release:(Required)

Intake Assessment

Entitlement Information

Treatment Plans (ITP, ITRP and Review)

Psychiatric Assessment, Notes, Medication Log

Transfer/Discharge Summary

None of the Above

I revoke consent for the above individual:(Required)

First Last

Consumer/Guardian

I have revoked consent as of:(Required)

Month

Day

Year

I acknowledge release(s) expire 1 year from the date of signature.(Required)

Consent is provided:(Required)

Consumer/Guardian Signature:(Required)

Date(Required)

Month

Day

Year

Release of Information

EMERGENCY CONTACT

PRIMARY CARE

MENTAL HEALTH PROVIDER

SCHOOL

OTHER

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