BALZ05 Notice of Privacy Practices

Notice of Privacy Practices and Disclosure of Health Information Notice of Privacy Practices (HIPAA)

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Patient Name *

First Name

Middle Name

Last Name

Date of Birth *

Date

I authorize Balanced Mental Health of AZ to release protected health information to persons or entities directly associated with and engaged in carrying out a treatment plan for the patient. Balanced Mental Health of AZ may use and release any part of my medical records, including substance abuse, mental/behavioral health, and medical, necessary to the process of billing third party payers for services rendered on my behalf. I clearly understand that all my information will be kept confidential. I consent for Balanced Mental Health of AZ to use technology, including automated technology such as auto-dialing or pre-recorded messages, to contact me at the address, e-mail address, or telephone number, including any cell phone/wireless number that I have provided; I understand that this information will be used to review, investigate, make payment of a claim, to review records for quality improvement initiatives, audit compliance, utilization management, or complaint resolution.

I understand that I may revoke this consent in writing, except to the extent that the organization has already acted in reliance thereof. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by 45 CFR Section 164.506 of the Code of Federal Regulations.

Disclosure of Health Information

I give you permission to call, speak with, and/or release any health information to the following person(s):

	Name	Relationship	Phone Number
1.
2.
3.

I give you permission to call, speak with, and/or release any health information to the following person(s): Please include NAME, RELATIONSHIP & PHONE

I understand I may revoke this consent in writing at any time by submitting request to the clinic at 14122 W McDowell Rd Suite 103 Goodyear, AZ 85395

Digital Signature Authorization: *

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Patient/Legal Guardian Signature *