Instructions for Completing ODM 10221
Standard Authorization Form

This standard authorization form should be used by an individual or their personal representative to give consent o the release of personal health information. This form Is not a patient access request under 45 CFR 164.524. Which form do you use If you are a Pat 2 program [Substance Use Disorder (SUD) provider), Or you ae releasing records obtained from a Part 2 program, use FORM B. In al other cases, use FORM A. Form A does not need to be used when the exchange of information is for the purposes of treatment, payment and healthcare operations under HIPAA.

• Part 2 programs are federally assisted individuals or entities that hold themselves out as providing, and provide, substance use disorder diagnosis, treatment or treatment referral. For more information, see 42 CFR 2.11.

 Section I (both FORM A and FORM B)

• Enter the requested information or the Individual whose health Information I to be released.
• Individuals are not required to provide Social Security Number (SSN). If the SSN or additonal identifying Information is missing, an entity may not be able to identify the individual in order to respond to the request. An option is to provide the Tast digits of the SSN.

 Section Il (Form A)

• “Disclosing Entity (Name of Covered Entity) s the health plan/insurer o provider who has the individual’s PHI which will be released. Enter the name of the Covered Entity as well the contact Information.
• “Reciplent (Person or Entity} – st the person or organization who should receive the PHI. Ener the contact information (phone number, email address, fax number, mailing address, etc.)

 Section II (Form B)

• “Disclosing Entity (Name of Holder of Part 2 program Information) is the person or entity who has the individual’s substance use disorder Information to be released. Enter the name of the Holder of Part 2 Program Information as well 2s the contact information. You may use a general description such as “any drug or alcohol treatment program that has provided services to the Individual” More than one person or entity may be named.
• “The information i to be provided to the following” – ls the person or organization who should receive the substance use disorder information. This can be an Individual, provider, a third party payer (health plan/insurer), or a non-treating entity, such as a health Information exchange, a parole officer, or a drug court program. More than one person or entity ‘may be named.
• Use separate FORM B for each person or organization that will be disclosing Information.
• If “Named Non-Treatment Provider (such as an intermediary or research entity)” s selected then a, b, and/or c must be completed too. The form is not complete f this box is checked ond no additional information i provided in 0, b, and/or c
  • Atreatment provider relationship exists where an individual has agreed to o s required to be diagnosed, evaluated, or treated by, or to accept consultation from, an Individual or entity who provides or agrees to provide the serice. For mre Information see 42 CFR 211.
• Enter the contact Information (phone number, emall address, fax number, mailing address, etc).

Section lII {both FORM A and FORM B}:

• “Reason for Disclosure” must tell why the individuals Information i being released.
• “Health Information to be disclosed” – must give a complete description of the information to be released. For Form { please clearly specify the substance use dsorder Information that may be released.
• Specify Time Period, I desired” Is to be used, If necessary, to Indicate a specific date range for the information to be disclosed (e.. 7/1/2017 t0 1/1/2018).

 Section IV bath FORM A and FORM B)

• “Expiration Date or Event” s the specific date or event upon which the consent wil expire. Event may be defined as t reason for the authorization or consent (.8. Insurance claim). If no date or event s provided, the authorization or cot will expire In one year.
• The Individual whose Information i being released should sgn and date the form. If the individual s not able to sign form, the personal representative should sign and date it. Ifa personal representative signs the form, indicate the relationship of the personal representative by selecting the appropriate box. Disclosing entity may require proof.