Name/alias _______________________________ DOB: _________ Social Security # ______________

Request for protected health information (PHI), from another entity:  I authorize the entity described below (Releasor) to provide to the Juvenile Assessment Center for Wayne County (JAC) (Recipient), only, the protected health information described in this Authorization.

Releasor:

Name: __________________________________

Address: _________________________________

City, State, Zip ___________________________ 

Attention: ________________________________

Recipient:

The Juvenile Assessment Center for Wayne County
7310 Woodward, Suite 601
Detroit, MI 48202

Authorization for JAC to release protected health information (PHI), to another  entity:  I authorize the Juvenile Assessment Center for Wayne County (JAC) (Releasor) to release information, including protected health information, to the entity described below (Recipient), only:

Releasor:

The Juvenile Assessment Center for Wayne County
7310 Woodward, Suite 601
Detroit, MI 48202

Recipient:

Name: __________________________________

Address: _________________________________

City, State, Zip ____________________________ 

Attention: ________________________________

Protected Health Information requested to be released:  Information about communicable disease and/or serious diseases and/or Virus (HIV) Infection, Acquired Immunodeficiency (AIDS), venereal disease and tuberculosis, if any; alcohol and drug abuse information protected under the regulations in 42 Code of Federal Regulations (CFR) Part II, if any; psychological services records, and social services records, if any; psychiatric records, if any; and dental records, if any, to be released to the above-listed individuals or organizations.  This information shall be furnished only under the following conditions:

1)	Specific information as indicated below (Check one or more boxes):
•	
	Medical Diagnosis
	Discharge Summary
	Substance Abuse
	Acquired Immunodeficiency Syndrome
	Current Medications
	Psychiatric/psychological Evaluation(s)
	Dental
	Confinement Record
	Laboratory Report
	Treatment Plan
	HIV Infection

	Other:  ________________________________________________________________________
		(Describe in reasonably specific detail)

2)	Dates of treatment/confinement ______________________

3)	The purpose for such disclosure is:  
		At the request of the individual, OR
		The following specific purpose(s): ___________________________________________

4) 	This authorization shall remain in effect for 90 days, unless one of the following is checked:
		This authorization shall remain in effect until (date): ______________________________
		This authorization shall remain in effect until the conclusion of the underlying court proceedings, if any, 			or until the conclusion of the following specific event: _______________________________________

I understand that I have the right to revoke this authorization, at any time, provided that the revocation is in writing.  However, my revocation will not be effective to the extent that action has already been taken in reliance on this authorization.  For all records protected by 42 CFR, this authorization will expire without express revocation 3 days after the information has been released.  Any re-disclosure of this information is not permitted without specific authorization, except as is consistent with the Privacy Rule, 45 CFR § 164.501 et. seq., enacted pursuant to the Health Insurance Portability and Accountability Act (HIPAA), Public Law 104-191.

I understand that signing this authorization is not a condition for the Juvenile Assessment Center to provide treatment or arrange payment for the health-care services rendered for me (or the youth for whom I am personal representative or guardian).  

I understand that I have the right to inspect or copy the protected health information to be used or disclosed; however, this right does not apply to some categories of material, including psychotherapy notes, and information obtained in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding.  I understand that protected health information used or disclosed to others under this Authorization may be subject to redisclosure by the recipient of this information, and then it will no longer be protected by the HIPAA Privacy Rule.

Remuneration (check one):  Direct or indirect remuneration to the Juvenile Assessment Center from a third party from the use or disclosure of the requested information:
	will result 
	will not result.

I acknowledge that I have received my own copy of this authorization.

____________________________________		______________________________________________
Witness Signature/Date 					Signature of Patient/Youth 14 Years of Age or Older/Date

					___		______________________________________________
							Relationship to Patient [Parent of Minor, Legal Guardian, 
							or Personal Representative]

[If Legal Guardian or Personal Representative, attach a copy of the Letters of Authority.]