WSH Form No 0153.dot 200153 0153

User Manual: 200153

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WSH Form No. 153
(4/3/2003)

DMHMRSAS AUTHORIZATION FOR USE/DISCLOSURE OF PROTECTED HEALTH INFORMATION
Facility Name
Telephone Number

Western State Hospital, P.O. Box 2500, Staunton, VA 24402-2500
(540) 332-

Fax Number

(540) 332-

Patient Name: Last, First, MI
DOB:

SS# (optional)

Extent or nature of use/disclosure is limited to: (Check √ or list all that apply)
Discharge Summary
History & Physical
Psychiatric Evaluation
Progress Notes
Lab Work
Consultations
HIV/AIDS Information
Substance Abuse Information
Other: List All

Social Work Assessment
Physician Orders
Treatment Plan
Psychological Evaluation

Diagnosis/Treatment
Discharge Planning
Specified purpose or need for use/disclosure is:
Other, Specify
Insert Specific Facility Name & Name of Responsible Person (e.g. “Facility director or his authorized designee”)
Permission is
hereby given to:
To disclose information to:
Street Address, City, State, Zip

(Name, title and organization)

Phone/Fax #

I also authorize the recipient to use the information received pursuant to this authorization.
As the person signing this authorization, I acknowledge that I am giving my permission to the above-named person/class of persons to disclose
and use protected health information. I further acknowledge that:
•
I may refuse to sign this authorization.
•
DMHMRSAS/Western State Hospital cannot condition the provision of treatment to me on my signing of this authorization.
•
The original or a copy of this authorization shall be included with my original records.
•
I have the right to revoke this authorization at any time, except to the extent that action has been taken in reliance on it, by delivering
the revocation in writing to the provider who is in possession of my health care records.
•
There is a potential for any information disclosed pursuant to this authorization to be subject to re-disclosure by the recipient and,
therefore, no longer protected by the provisions of the HIPAA Privacy Rule. If this information is being disclosed from records
protected by the Federal substance abuse confidentiality rules (42 CFR part 2), the Federal rules prohibit the recipient from making
any further disclosure of this information unless further disclosure is expressly permitted by your written authorization or as otherwise
permitted by 42 CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose.
The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.
If not previously revoked, this authorization will expire in:
The information may be disclosed effective:
This authorization

does

90 Days

One Year

Immediately

On (specify date or event)
(specify date)

does not extend to information placed in my record after the date I signed this form.

Signature of Individual (adult) or Legally Authorized Representative

Relationship

Date Signed

Signature of Minor (if required by law)

Date Signed

Witness (optional)

Date Signed
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