The California MH 5671 form is an authorization document used to release confidential patient information related to mental health services. This form ensures that the patient's rights are protected while allowing necessary information to be shared with authorized parties. To fill out the form, click the button below.
The California MH 5671 form is a crucial document designed to facilitate the release of confidential patient information related to mental health services. It is used when a request is made for patient information, ensuring compliance with both state law and federal regulations, such as the HIPAA Privacy Rule. This form requires the signature of the patient or their authorized representative, like a parent or guardian, to validate the request. Patients have the right to refuse to sign, and in such cases, their information will not be released unless mandated by law. The form outlines the specific information to be disclosed, which can include anything from entire medical records to specific evaluations and assessments. It also specifies the purpose of the disclosure, whether for evaluation, treatment planning, or other reasons. Importantly, the form emphasizes that treatment or payment cannot be conditioned on the authorization, protecting the patient's rights. Furthermore, it allows patients to inspect or obtain copies of their protected health information, ensuring transparency throughout the process.
State of California - Health and Human Services Agency
Department of Mental Health
AUTHORIZATION FOR RELEASE
Confidential Patient Information
OF PATIENT INFORMATION
See W&I Code Section 5328 and
MH 5671 (Rev. 06/08) Page 1 of 3
HIPAA Privacy Rule CFR Section 164.508
___
INSTRUCTIONS: Use this form to obtain the required authorization when a request is received for patient information, unless the request received is a facsimile of this form or contains all of the required information. Obtain signature of patient or parent/guardian/ conservator. If patient signs, obtain “witness signature.” List the information released per this authorization on the back of this form.
The hospital shall not condition treatment or payment based on this authorization. The patient may refuse to sign the authorization. If the authorization is not signed, the information shall not be released except when required by law. Upon request, the patient may inspect or be provided a copy of the protected health information to be disclosed by this authorization.
______
Patient’s Name
Birth Date
______________
Month Day Year
I,
and/or
Name of Patient
Name of Parent/Guardian/Conservator
hereby authorize
Name of Agency/Person/Organization
Address (Street, City, State and Zip Code)
to release to
the information specified on Page 2 of this form with the knowledge that such release discloses the fact that mental health services have been/are being provided.
MH 5671 (Rev. 06/08) Page 2 of 3
HIPAA Privacy Rule C.F.R. Section 164.508
This disclosure of information* is required for the following purpose(s): (initial applicable
areas)
Evaluation
Treatment Planning/Course
Other (Specify) __________
and shall be limited to releasing the following types of information (initial all applicable areas): from (date required) __________________to (date required) __________________;
or any information/records indicated, regardless of date.
Entire Record
Diagnosis
Psychiatric Evaluation
Discharge Summary
Social History
Individual Treatment
Plan
Legal Information
Medical, Neurological
Assessment, Lab Tests,
e.g., EEG, EKG, etc.
Seclusion and/Restraint Information
HIV Tests Results
Other Evaluations/ Assessments (specify)
_____________________
Results of Psychological/ Vocational Testing Conference(s) Date(s)
____________________
Other (specify)
*The information disclosure under this authorization may be subject to re-disclosure by the recipient if allowed or required by law. This authorization becomes effective
(Month/Day/Year) ___. This authorization may be revoked in writing by the
undersigned at anytime except to the extent that action has already been taken. If not
revoked, it shall terminate at the end of (check one):
6 months
One year or
Specify Date ____________________.
I understand that I am to receive a copy of this authorization.
Date:
Signature of Patient
Month
Day
Year
Signature of Parent/Guardian/Conservator, if Applicable
Witness Signature
Signature of Professional*
Date
Person Obtaining Authorization Date
*Professional for this authorization refers only to a Physician, Licensed Psychologist or Social Worker with a Master’s degree in social work, or Marriage and Family Therapist who approves this patient initiated request for release of patient records.
MH 5671 (Rev. 06/08) Page 3 of 3
RECORD OF RELEASE OF INFORMATION
The following information was released to the named party specified on the front of this form. Identify the specific dates of the reports, records, items released.
Individual Treatment Plan
Other:
Medical, Neurological Assessment, Lab Tests, e.g., EEG, EKG, etc.
Results of Psychological/ Vocational Testing
Conference(s) Date(s)
Released By (Name & Title)
Date Released
Filling out the California MH 5671 form requires careful attention to detail. This form is used to authorize the release of confidential patient information. Ensure that all sections are completed accurately to facilitate the processing of the request.
What is the purpose of the California MH 5671 form?
The California MH 5671 form is used to obtain authorization for the release of confidential patient information related to mental health services. It ensures that patient information is shared only with the consent of the patient or their authorized representative, such as a parent or guardian. This form is vital for protecting patient privacy while allowing necessary information to be disclosed for purposes like treatment planning or evaluation.
Who needs to sign the MH 5671 form?
The form requires the signature of the patient, or if the patient is unable to sign, the signature of a parent, guardian, or conservator. If the patient signs the form, a witness signature is also needed. This process ensures that the authorization is valid and that the patient or their representative fully understands the implications of releasing their mental health information.
Can a patient refuse to sign the MH 5671 form?
Yes, a patient can refuse to sign the MH 5671 form. If the authorization is not signed, the information cannot be released, except in situations where the law requires disclosure. It's important for patients to know that their treatment or payment will not be conditioned on their decision to sign or not sign this authorization.
How long is the authorization valid?
The authorization provided by the MH 5671 form is valid for a specific duration, which can be set for six months, one year, or until a specified date. If the authorization is not revoked in writing before the expiration, it will automatically terminate at the end of the designated period. Patients should be aware of this timeframe to ensure their information is shared only as intended.
Filling out the California MH 5671 form can be straightforward, but there are common mistakes that people make. These errors can delay the process or even lead to the denial of requests for patient information. Understanding these pitfalls is essential for ensuring that the form is completed correctly.
One frequent mistake is failing to provide the patient's full name and birth date. This information is crucial for identifying the individual whose records are being requested. Omitting or misspelling this information can lead to confusion and delays in processing the request.
Another common error is not obtaining the necessary signatures. The form requires the signature of the patient or their parent/guardian/conservator. Additionally, a witness signature is needed if the patient signs. Without these signatures, the authorization may not be valid.
People often overlook the specific purpose for the release of information. It is important to initial the applicable areas on the form, indicating whether the information is needed for evaluation, treatment planning, or other purposes. Failing to specify the purpose can lead to misunderstandings about what information is being requested.
Not specifying the types of information to be released is another mistake. The form provides various options, such as entire records, diagnosis, or specific evaluations. Initialing the relevant areas ensures that only the necessary information is disclosed, protecting patient privacy.
Many individuals also forget to indicate the effective dates for the authorization. The form asks for the date range during which the information can be released. Leaving this section blank can result in the authorization being deemed incomplete.
Lastly, some people neglect to keep a copy of the authorization for their records. It is essential to receive a copy of the completed form. This serves as proof of the authorization and can be helpful in case any issues arise later on.
By being aware of these common mistakes, individuals can fill out the California MH 5671 form accurately. Taking the time to ensure all sections are completed correctly will help facilitate the release of patient information in a timely manner.
When completing the California MH 5671 form, several other documents may be necessary to ensure a comprehensive understanding of patient rights and the release of information. Below is a list of these forms, each serving a specific purpose in the process of obtaining and managing patient information.
These documents work together to protect patient rights and ensure that sensitive information is handled appropriately. Understanding each form's purpose can help facilitate a smoother process for both patients and healthcare providers.
The California MH 5671 form is used for authorizing the release of confidential patient information. Several other documents serve similar purposes in different contexts. Here’s a list of eight documents that are similar to the MH 5671 form:
When filling out the California MH 5671 form, it’s important to ensure accuracy and compliance with regulations. Here are five things you should and shouldn’t do:
Understanding the California MH 5671 form is essential for anyone involved in mental health services. However, several misconceptions can lead to confusion. Here are six common misconceptions:
Clarifying these misconceptions can help ensure that the process of obtaining mental health information is smooth and compliant with legal requirements.
When filling out and using the California MH 5671 form, consider these key points: