Mental Health Release Of Information Form

Collaborate with your colleagues at other practices while meeting your HIPAA obligations using our free mental health release of information form.

By Ericka Pingol on Mar 06, 2024.

Fact Checked by Ericka Pingol.

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What Is A Mental Health Release Of Information Form

Mental health practitioners often find themselves needing to consult with a colleague working outside of their practice to offer their patients the best possible care. Additionally, patients often transfer mental health practitioners and as a result, need their records to be sent between practices. These scenarios present patient data privacy issues, as discussing the details of a patient’s case or sharing their medical records presents a potential violation of the patient’s right to privacy under .

That’s where our form comes in! Your patient can legally authorize you to disclose their mental health records with another person or organization. This is an important procedure to undertake prior to discussing, consulting with, or sharing your patient’s medical information with someone else.

There are several reasons a patient may wish for their information to be disclosed to someone else, whether that is to a colleague of yours to aid your patient’s treatment, to a new practice they are moving to, or to an insurer or employer. This form is designed to make authorizing information disclosure as easy as possible for your patient in these scenarios.

Printable Mental Health Release Of Information Form

Download these templates for Mental Health Release Of Information forms to improve your paperless intake process and HIPAA compliance.

How To Use This Template For Mental Health Release Of Information Form

Before you provide this form to your patients, it’s important you understand each section so you can answer any questions they may have. Let’s go through these simple steps to use our mental health release of information form now.

Step One: Patient Information

The first step is for your patient’s information and contact details. These details are important for ensuring you can correspond with your patient regarding this authorization, and for ensuring you have the correct patient.

Step Two: Authorization

This section details the organization that will be sending the information. This could be the practice, or the individual practitioner, who currently holds the patient’s mental health information.

It’s important your patient understands how to specify any exclusions they wish to make to the authorization and the purpose for the authorization. If the authorization is for a purpose other than continuing care, billing, insurance, or legal proceedings- your patient can enter the purpose for the disclosure in the “Other” section. 

Step Three: Disclosure

This section details the organization that will be receiving the information. This could be the patient’s new therapist, insurance company, school or employer, lawyer, or themselves. 

Step Four: Expiration

The expiration section is for your patient to put an end date to the authorization they have provided with you. If they have no preference, they can set the authorization to be valid until they revoke it in writing, otherwise, they can set a date they want the authorization to expire. 

Step Five: Statements of Rights

The statements of rights are six bullet points for your patient to read through and ensure they understand before authorizing the disclosure of their information. These statements are crucial so your patient understands they cannot have treatment conditioned on their authorization, and their rights surrounding revoking their authorization under HIPAA.

Step Six: Signature Authorization

The final section is for the signature of your patient, or their representative. Your patient’s representative may be the parent or legal guardian for a minor patient, or a legal representative for patient incapable of authorizing the release of their own information.

Mental Health Release Of Information Example (Sample)

While some people like reading about a new resource before trying it out, others find the best way to learn is through seeing a finished example. We have both of these covered with our example mental health release of information form we have provided here! Take a look at this sample form to see what this form might look like once it’s complete. The purpose and exact details will of course vary from patient to patient, but the structure will remain the same each time your patients use this form.

Download this Mental Health Release Of Information Example here:

Mental Health Release Of Information Example (Sample)

Who Can Use this Printable Mental Health Release Of Information Form (PDF)?

While this template is designed to be filled in by patients, it is useful for all kinds of mental health practitioners as well. This form can be provided to patients by:

  • Counselors
  • Psychotherapists
  • Clinical Psychologists
  • Psychiatrists
  • Mental health nurses
  • Social workers

Or any other mental health workers who find themselves needing to transfer patient information somewhere else. Additionally, the form itself may be handled by a medical administrator or receptionist at a practice, and so administrators working at the clinics of any of the above specialists may also benefit from our simple and interactive PDF release of information form. 

This form may be provided to patients in order to facilitate their treatment by collaborating with others, or upon the patient’s request. Patients may request the disclosure of their information for insurance or legal purposes, transferring practices, employer screening, or for their personal use. This form can be used in any number of these situations, so is a very useful tool to have!

Why Is This Form Useful For Mental Health Practitioners?

Aid collaboration: This form can be a great help to clinicians if they find themselves needing to collaborate or discuss a case with one of their colleagues. Having the authorization to disclose patient information means you can collaborate with experts to create the best treatment plan for your patient.

Ensure your patients understand their rights: In order to legally disclose patient information to a colleague outside their practice, the clinician can use this simple form to obtain authorization from their patient while ensuring their patient understands their rights regarding information disclosure. 

Provide efficient service to your patients: If a past patient of yours has transferred to a new practice, or is needing evidence of their mental health treatment for their employer, they’ll be grateful that you’ve got a plan in place for ensuring the authorization process goes smoothly. Our template is simple to follow and written in plain language to ensure your patients can take control of their medical information.

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Why Use Carepatron For Release Of Information Form Template Mental Health?

It’s not just the security of your data storage you need to worry about; if you’re transferring patient data to another institution, you need to ensure the method of sending information is secure as well. Carepatron is a great way to securely store, access, and transfer your patients’ sensitive information digitally, and you can find this mental health release of information form, along with many other useful templates, right from within Carepatron.

Carepatron is a state-of-the-art, highly integrated practice management software. Its many (many!) features are completely intuitive and complete with a sleek and user-friendly design, it will revolutionize how you complete your admin tasks.

With appointment scheduling, billing and payments, telehealth consultations, SMS and email automated appointment reminders, AI-powered dictation software, and a community library chock full of useful templates designed to save you time- signing up for Carepatron might be the best decision you make for your practice! Find out why 10,000 + healthcare practitioners have switched to Carepatron.

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What is meant by the release of information?
What is meant by the release of information?

Commonly asked questions

What is meant by the release of information?

The release of information refers to purposefully sharing a patient’s confidential information with another person or organization, outside of your practice. There are many situations where this could be necessary, but it is important that you have the proper authorization before releasing information in order to comply with your legal obligations.

What is required for the release of information in healthcare?

A release of information authorization must be completed by the patient or their legal representative and needs to include the name of the person or organization sending the information, the name of the person or organization receiving the information, an expiration point for the authorization, the nature of the information to be shared, the purpose of the authorization, and statements of the patient’s rights regarding this authorization and its revocation.

Who signs the release of information form?

The release of information form needs to be signed by the patient whose information is to be released, or their legal representative. The practitioner in possession of the patient’s mental health information cannot share this with another organization without the authorization of the patient.

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