SECTION 3: OTHER IMPORTANT INFORMATION
By signing this form, I understand:
- I am giving consent to share my behavioral health and substance use disorder information as indicated in Sections 1 and 2. Behavioral health and substance use disorder information includes, but is not limited to, referrals and services for alcohol and substance disorders.
- My information may be shared among each individual and organization listed in Section 1.
- My information will be shared to help diagnose, treat, manage, and pay for my health needs.
- My consent is voluntary and will not affect my ability to obtain treatment, payment for treatment, and health insurance or benefits.
- My health information may be shared electronically.
- Other types of information may be shared with my behavioral health and substance use disorder information. HIPAA and the Michigan Mental Health Code allows my providers and other agencies to use and share most of my health information without my consent in order to provide me with treatment, receive payment for my care, and coordinate my care.
- This form allows me to choose to share my health information with past, current, and future treating providers under Sub-Section 1c. If I agree to share my health information in this way, I can request a list of all of the individuals and organizations who received my health information within the last two years. I must make this request to the organization(s) under Sub-Section B in writing. I can ask my provider for assistance if I am not sure how to contact the organization(s) under Sub-Section B.
- The sharing of my health information will follow state and federal laws and regulations.
- This form does not give my consent to share psychotherapy notes as defined by federal law.
- I can withdrawor revoke my consent at any time. I understand that any information previously shared with or in reliance upon my consent cannot be taken back.
- I should tell all individuals and organizations listed on this form when I withdraw my consent.
- I can have a copy of this form.
- My consent with expire on the following date, event, or condition unless I withdraw my consent. (If this field is left blank, the consent will expire 1 year from the signature date.)