Veritas Collaborative Authorization to Exchange Confidential Healthcare Information

Complete this form in its entirety if you want Veritas to use or disclose your confidential healthcare information to a treatment facility, provider, or person other than yourself. Incomplete forms will not be processed.

Is the purpose of this authorization to improve assessment and treatment planning, share information relevant to treatment, and when appropriate coordinate treatment services to further mental health evaluation, treatment or care, treatment planning, continuity of care, housing, and/or financial communication throughout pre-admission and admission to Veritas as well as following discharge from Veritas for all past, present, and future dates of treatment/care for the life of this authorization?*
What is the purpose of this authorization? (select all that apply)
$
$

Description of Information to be Used or Disclosed

*Required

Please describe the requested information for use or disclosure:
(Select all that apply)*
Is this request for all treatment dates or specific date(s)?*
MM/DD/YYYY - MM/DD/YYYY

Name of Person/Practice/Facility/Treatment Provider with whom Veritas can Use or Disclose Information

(919) 555-5555
Person/Treatment Provider Address:*
Person/Treatment Provider relationship to patient:*
Are we authorized to exchange confidential health care information with others involved in your care at this Practice/Facility/Treatment Provider?*

Patient Information

First Name, Middle Initial, Last Name
Patient's Date of Birth:*
MM/DD/YYYY
Patient's Address:*
First Name, Middle Initial, Last Name
Are you the patient or a personal representative completing this form on behalf of the patient?*
Please describe your authority to act of behalf of the patient:*
(919) 555-5555
Veritas Collaborative location:*

Authorization

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The information disclosed pursuant to this authorization may include information concerning mental health, use or treatment concerning drugs and/or alcohol abuse under 42 CFR part 2, HIV/AIDS and/or other communicable disease and genetic testing results. Psychotherapy notes are not released pursuant to this authorization.

Anyone, other than the patient, who signs this authorization must state his or her relationship to the patient and may be requested to provide proof of legal authority before Veritas can release PHI.

Releases of medical records based on this form may include future dates of care. By releasing communications involving future records, a request for records is being made concerning treatments not yet received, and conditions or diseases not currently known to the patient could be discovered during treatment, and that the authorization is being made without knowing what may be contained in those records.

I have the right to revoke this authorization at any time. I must request revocation in writing to Veritas Collaborative Attn: Medical Records at 4024 Stirrup Creek Drive Durham, NC 27703. I understand that revocation will not apply to PHI that has already been disclosed in response to this authorization.

Treatment, payment, enrollment, or eligibility for benefits may not be conditioned on whether I sign this authorization. Failure to sign this authorization, however, may impede my provider’s ability to provide continuity of care or best-practice care.

For compounding research authorizations, I have the right to opt into the research activities described in the unconditioned authorization.

Any disclosure of PHI carries with it the potential for unauthorized redisclosure, and the redisclosed PHI may not be protected by federal confidentiality rules, unless a state law applies that is stricter than HIPAA and provides additional privacy protections.

Unless specifically requested in writing that disclosure be made in a certain format, Veritas reserves the right to disclose PHI as permitted by this authorization in any manner deemed appropriate and consistent with applicable law, including, but not limited to, verbal, paper, or electronic format.

Requests for copies of medical records may be subject to reproduction fees in accordance with federal/state regulations. Notification as to cost, if any, will be provided to the patient or personal representative upon receipt of request.

If I fail to specify an expiration date/event/condition, this authorization will expire 1 year from the date signed, or upon the occasion of the patient’s 18th birthday, legal emancipation, or upon written revocation of consent.

This request is entirely voluntary on my part.

By typing my name below, I acknowledge my understanding of the above information that has been provided to me, and I, hereby, authorize Veritas Collaborative, LLC, (Veritas) to disclose to and/or obtain the information specified on this form from the above-listed Practice/Facility/Person/Treatment Provider.

Name of Patient, Parent/Guardian, or Personal Representative*
Today's Date:*
MM/DD/YYYY
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