WSH Form No 0153.dot 200153 0153
User Manual: 200153
Open the PDF directly: View PDF 
.
Page Count: 1
WSH Form No. 153
(4/3/2003)
DMHMRSAS AUTHORIZATION FOR USE/DISCLOSURE OF PROTECTED HEALTH INFORMATION
Facility Name Western State Hospital, P.O. Box 2500, Staunton, VA 24402-2500
Telephone Number (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 Social Work Assessment
Psychiatric Evaluation Progress Notes Physician Orders
Lab Work Consultations Treatment Plan
HIV/AIDS Information Substance Abuse Information Psychological Evaluation
Other: List All
Specified purpose or need for use/disclosure is: Diagnosis/Treatment Discharge Planning
Other, Specify
Permission is
hereby given to:
Insert Specific Facility Name & Name of Responsible Person (e.g. “Facility director or his authorized designee”)
To disclose information to:
(Name, title and organization)
Street Address, City, State, Zip
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: 90 Days One Year
On (specify date or event)
The information may be disclosed effective: Immediately (specify date)
This authorization does 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
