Release for COC - Primary Care Provider

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Release for Coordination of Care - Primary Care Provider

For Office Use Only

PCN # (For office use only)

MMHC Provider (For office use only)

Office Location (For office use only)

Client Information

Are you the Client (Patient)?*

Yes, I am the Client (Patient) No, I am the Parent / Guardian / Legal Representative of the Client (Patient)

How old is the Client?*

Age 11 or younger Age 12 to 15 Age 16 or 17 Age 18 or older

Client's Legal Name*

First Name

Last Name

Previous Last Names (if any, or "N/A" if none)*

Date of Birth*

Primary Phone Number (e.g. Cell Phone)*

Format: XXX-XXX-XXXX

Please describe your primary phone number:*

Home Phone Cell Phone Other

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Email Address*

Release for Coordination of Care

Who has the information you would like released?

Name: Minnesota Mental Health Clinics

Phone Number: 651-454-0114

Fax Number: 651-454-3492

Address: 3450 O'Leary Lane, Eagan, Minnesota 55123

Please select one option regarding MMHC (Client)*

I AGREE to allow MMHC to release my treatment data to my Primary Care Physician. (continue filling out form) I DO NOT AGREE to allow MMHC to release information to my Primary Care Physician. (sign & date form)

Please select one option regarding your Primary Care Physician (Client)*

I AGREE to allow my Primary Care Physician to release my treatment data to MMHC. (continue filling out form) I DO NOT have a Primary Care Physician that I am currently seeing. (sign & date form)

Please select one option regarding Dakota County (Client)*

I AGREE to allow MMHC to release my treatment to Dakota County for services. (continue filling out form) I DO NOT AGREE to allow MMHC to release my treatment to Dakota County. (sign & date form)

Primary Care Physician Information

Clinic Name*

Physician Name*

First Name

Last Name

Clinic Phone Number*

Format: XXX-XXX-XXXX

Clinic City Location*

Clinic Fax Number

Format: XXX-XXX-XXXX

Clinic Address

Address Line 1

Address Line 2

City

State

ZIP Code

Information to be Disclosed:

Any information relating to Mental Health Status or Medication

Reason for Release:

Continuation of care
Ongoing consultation and exchange of information
Telephone contact

Revocation:

I understand that I may revoke this consent at any time by providing written notice, and after 24 months this consent automatically expires. I understand that once the information is released by this authorization, we cannot prevent the re-disclosure by the above named party to a third party. I also understand this information will be shared with the treatment team and that refusal to sign this release will not condition treatment being provided. I have been informed of what information will be given, its purpose, and who will receive the information.

Authorization:

I authorize Minnesota Mental Health Clinics to release the information marked above.

Client Signature Required

Client Signature*

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Use your mouse or finger to draw your signature above

Date (Client)*

Client Signature

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Date (Client)

Parent / Guardian Signature Required

Parent / Guardian Name*

First Name

Last Name

Parent / Guardian Signature*

[clear]

Use your mouse or finger to draw your signature above

Date (Parent / Guardian)*

Parent / Guardian Signature

Parent / Guardian Name

First Name

Last Name

Parent / Guardian Signature

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Use your mouse or finger to draw your signature above

Date (Parent / Guardian)