Medical Records Request - Northeastern Center

Please use the form below to request medical records.

General

Northeastern Center, Inc abides by all federal and state confidentiality laws including HIPAA (Health Insurance Portability and Accountability Act), and 42 C.F.R. Part 2. By signing this authorization, I acknowledge, accept and agree. This information has been disclosed to you from records in which confidentiality is protected by federal law. Federal Regulations (42 CFE Part 2) prohibit the recipient from making any further disclosure of it without the specific written consent of the person to whom it pertains or except as otherwise permitted by SUD’s regulations. A general authorization for the release of medical or other information is NOT sufficient for this purpose. Information disclosed under 42 C.F.R. Part 2 cannot be used to criminally investigate or prosecute any client with an SUD except as provided for in 42 CFR Section 2.

Northeastern Center, Inc. will respond to all release of information requests within 72 hours. By federal law, all records requests must be completed within 30 calendar days. Per Federal and Indiana State laws, Northeastern Center is required to keep medical records for seven (7) years from the date of service.

Client Name(Required)

First Last

Requester Name (if different from client)

First Last

Address(Required)

Street Address City State ZIP Code

Relationship to Client(Required)

If Other, please specify:(Required)

Phone(Required)

Requester Email(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Last Four of Social Security Number(Required)

Drivers License Number

Release To / Release From

Please indicate the person or organization you wish NEC to send the records to.

Name or Other Specific Identification of Person(s) authorized to receive / make the request use or disclosure:(Required)

Organization/Provider

Contact

Type(Required)

Release To

Obtain From

Release To / From

Contact Type

Organization

Contact Name

First Last

Organization Address

Street Address Address Line 2 City State ZIP Code

Organization Phone

Organization Fax

Purpose of Disclosure

Please indicate the reason for release of information.

Purpose of Disclosure(Required)

Care Coordinator

Other

If other, please explain:

Expiration

Expiration(Required)

6 months

12 months

End of Agency Agreement

Start Date(Required)

MM slash DD slash YYYY

End Date

MM slash DD slash YYYY

Information to be Used or Disclosed

The information that can be disclosed under this authorization includes the following, if available:

ROI Type(Required)

Information Types:(Required)

Acknowledgement of Treatment

Billing Insurance Information

Intake Assessment

Psychiatric Evaluation Report(s)

Medications Prescribed

Discharge Summary / Plan

Progress Review / Summary

Screening Assessment(s)

Treatment Plan(s)

Progress Notes

Other

Please check all that apply.

Other(Required)

Records Start Date(Required)

MM slash DD slash YYYY

Records End Date

MM slash DD slash YYYY

Restrictions

Please list any restrictions or records that should not be sent.

Restrictions

Terms

- Under state and federal confidentiality provisions only the information specified can be released.

- Northeastern Center, Inc. cannot ensure the recipient will maintain the confidentiality of the mental health and/or SUD information authorized and released. If the person or organization obtaining this information is not a health care provider, health plan or covered under the federal privacy regulations, the information may no longer be protected by federal privacy laws including 42 C.F.R. Part 2 and could be re-disclosed.

- This authorization will be honored unless revoked in writing. Revocation may be made at any time except to the extent action has already been taken.

- Persons or organizations may not re-disclose substance abuse treatment information.

- I have been informed I.C. 16-39-2-5(d) restricts consent to release mental health services information to a 180-day period following the date of my signature. However, the specific purpose of this release extends beyond the 180-day period following my signature. I therefore, expressly waive my right to the 180day limitation and authorize this release to continue until the purpose of the release is fulfilled.

- This authorization is voluntary. I have been given the chance to ask questions and receive answers pertaining to this document.

- A list of entities to which my information has been released can be provided by Northeastern Center, Inc.

By checking these boxes, I agree that I have read, understand and agree to these terms.(Required)

NOTICE TO CLIENT: Signing this form is voluntary and not required to receive services with Northeastern Center, Inc.

ACCESS TO MY RECORD: I understand I can request a copy of my record. This request will be reviewed and approved by my therapist. I understand I can also review my records with my therapist by making an appointment. This request can take 30 days to complete and charges may apply.

Additional Information

Please note – The records released may contain alcohol and drug abuse information and/or information about Human Immunodeficiency Virus (HIV), Acquired Immunodeficiency Syndrome (AIDS), and AIDS Related Complex (ARC).

Alcohol / Drug Abuse(Required)

I authorize the release of information relating to referral and/or treatment for alcohol and drug abuse.

I PROHIBIT the release of information relating to referral and/or treatment for alcohol and drug abuse.

N/A

HIV / AIDS / Sexually Transmitted Disease / Communicable Disease(Required)

I authorize the release of information relating to HIV / AIDS / sexually transmitted disease / communicable disease.

I PROHIBIT the release of information relating to HIV / AIDS / sexually transmitted disease / communicable disease.

N/A

Digital Signature(Required)

By selecting the “I agree” button, I am signing this document electronically. I agree that my electronically typed signature is the legal equivalent of my manual/handwritten signature on this document. By selecting “I agree” using any device, means, or action, I consent to the legally binding terms and conditions of this document. I further agree that my typed signature on this document is as valid as if I signed the document in writing. I am also confirming that I am authorized to enter into this Agreement. If I am signing this document on behalf of a minor, I represent and warrant that I am the minor’s parent or legal guardian.

I may decline to electronically sign this document and withdraw my consent to sign this document electronically by contacting the Northeastern Center directly, which may delay transactions. I may contact the Northeastern Center separately to request to sign this document on paper or to receive a paper copy of the signed document. Any fees for such paper copy will be charged then by the Northeastern Center.

I Agree

Digital Signature Name(Required)

First Last

Date of Signature(Required)

Month

Day

Year

Phone

This field is for validation purposes and should be left unchanged.