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It explains that disclosed information may become part of the general medical record and could be re-disclosed, while behavioral health records are protected under applicable state law and federal Confidentiality of Alcohol and Drug Abuse Patient Records (42 CFR Part 2). It describes revocation rights, notice for recipients, inspection rights, copy distribution, and insurance contract validity rules for Virginia/DC.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":41,"@type":70,"position":76},"https://docshare.wps.com/template/letters/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/authorization-to-use-and-disclose-protected-behavioral-health-information-consent-form-read-online-free/288857/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/authorization-to-use-and-disclose-protected-behavioral-health-information-consent-form-read-online-free/288857.png","ImageObject",442,249,{"name":88,"@type":89},"Aldword","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-07","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",7,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What is the purpose of this authorization?","Question",{"text":109,"@type":110},"It authorizes release of behavioral health information to the primary care physician to coordinate care.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What happens after the information is disclosed?",{"text":114,"@type":110},"Disclosed behavioral health information becomes part of the general medical record and may be subject to redisclosure.",{"name":116,"@type":107,"acceptedAnswer":117},"Can I revoke this consent, and how?",{"text":118,"@type":110},"Yes. You may revoke in writing at any time, except to the extent action has been taken in reliance on the authorization. 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Iunderstand that as a result of this authorization, the behavioral health information disclosed pursuant to this authorization will become a part of my general medical record and thereby may be subject to redisclosure.  \nI understand that .my Behavioral Health records are protected under the applicable state law governing health care information that relates to mental health services. They may also be protected under federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records (42 CRF Part 2) .  \nI also understand that I may revoke this consent at any time (in writing) except to the extent that action has been taken in reliance on it. To revoke this authorization, please provide a written statement to the Kaiser Permanente Behavioral Health Department. Kaiser Permanente may not condition treatment, payment, enrollment or eligibility for benefits on my providing or refusing to provide this authorization. FOR INSURANCE CONTRACTS ISSUED IN THE COMMONWEALTH OF VIRGINIA OR DISTRICT OF COLUMBIA: I understand that this authorization shall be valid:  \n(a) in the case of authorizations signed for the purpose of collecting information in connection with an application for an insurance policy, a policy reinstatement, or a request for change in policy benefits: (1) Thirty months from the date the authorization is signed If the application or request Involves life, accident and sickness, or disability insurance; (b) in the case of authorizations signed for the purpose of collecting information in connection with a claim for benefits under an insurance policy: (1) the term of coverage of the policy if the claim is for an .accident and sickness insurance benefit;  \n(2) the duration of the claim if the claim is not for an accident and sickness insurance benefit.  \nThis authorization will automatically expire twelve months from the date signed. I may obtain a copy of this authorization upon request. A copy of this authorization will be sent with my records to my Primary Care Physician. I also understand that I am entitled to inspect my records.  \nI AUTHORIZE:  \nKaiser Permanente Behavioral Health Department  \nTO RELEASE TO: My Primary Care Physician & Health Care Team Mid-Atlantic States Permanente Medical Group and  \nKaiser Foundation Health Plan of the Mid-Atlantic States, Inc .  \nOr Network Provider: - --- --- ---- -- --  \nPrint Provider's Name  \nThe following portions of my Behavioral Health chart:  \n☐ Diagnosis ☐Chemical Dependency Diagnosis & Treatment Information  \n☐Treatment Plan ☐Medication ☐ Other    \n\n| ☐ I understand that the Behavioral Health information being released pursuant to this Authorization will become part of my general medical record and may be subject to re-disclosure. |  |\n| --- | --- |\n| | Date  |\n| If other than patient, indicate relationship:   |  |\n\nPatient/Guardia n  Date:   \n(Signature)  \nIf other than patient, indicate relationship:    \nTO THE PERSON(S) RECEIVING RECORDS:  If this authorization pertains to alcohol or drug information  , please note that this information has been disclosed to you from records protected by federal confidentiality rules (42 CFR part 2) . Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by written authorization of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. A general authorization for release of medical or other information is not sufficient for this purpose. Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.  \n00264918 {3/2011)","cbCaitDmrOjVP0eJ","https://ap.wps.com/l/cbCaitDmrOjVP0eJ","pdf",85054,"English","# Authorization to Use and Disclose Protected Behavioral Health Information\n## Release purpose and effect on medical record\n## Legal protections and recipient obligations (42 CFR Part 2)\n## Revocation, validity, and expiration rules\n## Authorized parties and specific records to release","[{\"question\":\"What is the purpose of this authorization?\",\"answer\":\"It authorizes release of behavioral health information to the primary care physician to coordinate care.\"},{\"question\":\"What happens after the information is disclosed?\",\"answer\":\"Disclosed behavioral health information becomes part of the general medical record and may be subject to redisclosure.\"},{\"question\":\"Can I revoke this consent, and how?\",\"answer\":\"Yes. You may revoke in writing at any time, except to the extent action has been taken in reliance on the authorization. A written statement must be provided to the Kaiser Permanente Behavioral Health Department.\"}]","Authorization to Use and Disclose Protected Behavioral Health Information - Consent Form - read online free | PDF",1789634109]