AUTHORIZATION TO DISCLOSE INFORMATION

PRIVACY STATEMENT:
Disclosure of the social security number is voluntary and is requested for the purpose of accurate identification. Failure to disclose a social security number will not affect the disclosure of other information. The Department will not condition treatment on your agreement to authorize disclosure of your health information. The Department may, however, require that you authorize disclosure of your health information if needed to make a determination about your eligibility for benefits or enrollment in a Department health plan.

I hereby authorize Northland Health Centers permission to mutually exchange information with the ND Department of Health and Human Services.

 

The information disclosed is described below:

Name and identifying information of individual receiving SUD treatment; behavioral health treatment information supporting services, level of care, and medical necessity including diagnosis, screening, assessment, treatment plan, progress notes, UA, discharge summary, billing and payment.

The information identified above will be used for:

• Coordination of Care/Treatment/Discharge Planning
• Billing/Payment
• Eligibility Determination
• Pertaining to SUD Voucher Program and Medicaid

CLIENT CONSENT

This authorization is voluntary and remains in effect until the expiration date unless specifically revoked. This authorization may be revoked by written notice at any time, except to the extent that action has been taken in reliance on it. Refer to the Department's Notice of Privacy Practices for further description of revocation rights. Unless otherwise agreed in writing, information may be disclosed under this authorization in any form or medium, including verbal, written or electronic transmission. A photocopy of this authorization is as effective as the original.

Except for information protected under the federal regulations governing Confidentiality of Substance Use Disorder Patient Records, 42 CFR Part 2, there is the potential for information disclosed pursuant to this authorization to be subject to re-disclosure by the recipient and no longer protected by state or federal privacy laws.

MINORS SUBSTANCE USE DISORDER TREATMENT INFORMATION
In accordance with North Dakota State law, the signature of a minor 14 years of age or older is required to disclose Substance Use Disorder Treatment Information. Both the signature of a minor 13 years of age or younger and the signature of the minor's legal representative are required to authorize the disclosure of Substance Use Disorder Treatment Information, including disclosures to the minor's legal representative.

NOTICE TO RECIPIENTS OF SUBSTANCE USE DISORDER RECORDS: 42 CFR Part 2 prohibits unauthorized use or disclosure of these records. 

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