Article Guide
The California MH 5671 form is a crucial document designed to facilitate the release of confidential patient information in the realm of mental health. This authorization form ensures that patient privacy is respected while allowing for the necessary sharing of information among healthcare providers, family members, or other authorized entities. It outlines the process for obtaining consent from patients or their guardians, detailing the specific types of information that can be disclosed, such as psychiatric evaluations, treatment plans, and medical histories. Importantly, the form emphasizes that treatment or payment cannot be conditioned upon signing the authorization, reinforcing the patient's rights. Additionally, it includes provisions for revoking consent and specifies the duration of the authorization. By using this form, individuals can maintain control over their sensitive health information while ensuring that they receive the appropriate care and support they need.
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State of California - Health and Human Services Agency |
Department of Mental Health |
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AUTHORIZATION FOR RELEASE |
Confidential Patient Information |
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OF PATIENT INFORMATION |
See W&I Code Section 5328 and |
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MH 5671 (Rev. 06/08) Page 1 of 3 |
HIPAA Privacy Rule CFR Section 164.508 |
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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.
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Patient’s Name |
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Birth Date |
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Month Day Year |
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I, |
and/or |
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Name of Patient |
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Name of Parent/Guardian/Conservator |
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hereby authorize
Name of Agency/Person/Organization
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Address (Street, City, State and Zip Code)
to release to
Name of Agency/Person/Organization
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Address (Street, City, State and Zip Code)
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.
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State of California - Health and Human Services Agency |
Department of Mental Health |
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AUTHORIZATION FOR RELEASE |
Confidential Patient Information |
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OF PATIENT INFORMATION |
See W&I Code Section 5328 and |
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MH 5671 (Rev. 06/08) Page 2 of 3 |
HIPAA Privacy Rule C.F.R. Section 164.508 |
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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)
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Results of Psychological/ Vocational Testing Conference(s) Date(s)
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Other (specify)
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*The information disclosure under this authorization may be subject to
(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 ____________________. |
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I understand that I am to receive a copy of this authorization.
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Date: |
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Signature of Patient |
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Date: |
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Signature of Parent/Guardian/Conservator, if Applicable |
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Date: |
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Witness Signature |
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Signature of Professional* |
Date |
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Person Obtaining Authorization Date |
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*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.
State of California - Health and Human Services Agency |
Department of Mental Health |
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AUTHORIZATION FOR RELEASE |
Confidential Patient Information |
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OF PATIENT INFORMATION |
See W&I Code Section 5328 and |
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MH 5671 (Rev. 06/08) Page 3 of 3 |
HIPAA Privacy Rule C.F.R. Section 164.508 |
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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.
Entire Record
Diagnosis
Psychiatric Evaluation
Discharge Summary
Social History
Individual Treatment Plan
Other:
Legal Information
Medical, Neurological Assessment, Lab Tests, e.g., EEG, EKG, etc.
HIV Tests Results
Results of Psychological/ Vocational Testing
Other Evaluations/ Assessments (specify)
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Conference(s) Date(s)
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Released By (Name & Title) |
Date Released |
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Form Specifications
| Fact Name | Description |
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| Purpose of the Form | This form is used to obtain authorization for the release of confidential patient information. |
| Governing Law | The form is governed by California Welfare and Institutions Code Section 5328 and the HIPAA Privacy Rule (CFR Section 164.508). |
| Patient Signature | The patient or their parent/guardian must sign the form to authorize the release of information. |
| Witness Requirement | If the patient signs, a witness signature is also required on the form. |
| Information Types | The form allows for various types of information to be released, such as diagnosis, treatment plans, and medical records. |
| Revocation of Authorization | Patients can revoke their authorization in writing at any time, except for actions already taken. |
| Expiration of Authorization | The authorization remains valid for a specified period, such as six months or one year, unless revoked earlier. |
| Confidentiality Notice | Information disclosed under this authorization may be subject to re-disclosure by the recipient, if permitted by law. |
| Copy of Authorization | Patients are entitled to receive a copy of the signed authorization form for their records. |
California Mh 5671: Usage Guidelines
Completing the California MH 5671 form is essential for the proper authorization of patient information release. This process ensures that the necessary consent is obtained before any sensitive information is shared. Below are the steps to fill out the form accurately.
- Begin by entering the patient’s name and birth date at the top of the form.
- In the next section, indicate the name of the patient or the name of the parent/guardian/conservator who is authorizing the release.
- Fill in the name of the agency, person, or organization that will be releasing the information.
- Provide the address of the releasing agency, including street, city, state, and zip code.
- Next, enter the name of the agency, person, or organization that will receive the information.
- Complete the address of the receiving agency, including street, city, state, and zip code.
- Specify the purpose for the information release by marking the applicable areas.
- Identify the types of information to be released by initialing all applicable areas.
- Indicate the dates for the information required, if applicable.
- State the effective date of the authorization.
- Select the duration for which the authorization will remain valid by checking one of the provided options.
- Sign and date the form as the patient or parent/guardian/conservator.
- If applicable, obtain a witness signature and the signature of a professional, such as a physician or licensed psychologist.
- Complete the record of release of information section, detailing what information was released and the dates of the reports or records.
Your Questions, Answered
What is the purpose of the California MH 5671 form?
The California MH 5671 form is used to authorize the release of confidential patient information related to mental health services. This form ensures that patient information can be shared with specific agencies or individuals while complying with legal requirements. It is essential for protecting the privacy of the patient and ensuring that their information is only disclosed with their consent.
Who needs to sign the MH 5671 form?
The form must be signed by the patient or their parent, guardian, or conservator. If the patient is signing, a witness signature is also required. This process ensures that the patient or their representative fully understands and agrees to the release of their mental health information.
Can a patient refuse to sign the authorization?
Yes, a patient has the right to refuse to sign the authorization. If the authorization is not signed, the information will not be released unless required by law. It is important for patients to know they can exercise this right without any consequences regarding their treatment or payment.
What types of information can be released using this form?
The form allows for the release of various types of mental health information, including entire records, diagnoses, psychiatric evaluations, discharge summaries, social histories, and treatment plans. Patients can specify exactly what information they want to be disclosed by initialing the relevant sections on the form.
How long is the authorization valid?
The authorization remains effective for a specified period, which can be six months, one year, or until a date specified by the patient. If the authorization is not revoked, it will automatically terminate at the end of the chosen time frame. Patients should be aware of this duration when signing the form.
Can the patient inspect or receive a copy of their information?
Yes, patients have the right to inspect or obtain a copy of the protected health information that will be disclosed under this authorization. This provision allows patients to stay informed about their mental health records and how their information is being used.
What should be done if the patient wants to revoke the authorization?
If a patient wishes to revoke the authorization, they must do so in writing. The revocation can be made at any time, except for actions that have already been taken based on the signed authorization. It is advisable for patients to communicate their decision clearly to ensure their wishes are respected.
Common mistakes
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Missing Signatures: One common mistake is not obtaining the necessary signatures. Make sure to get the patient’s signature and, if applicable, the signature of a parent, guardian, or conservator. A witness signature is also needed if the patient signs.
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Incomplete Information: Failing to fill in all required fields can lead to delays. Ensure that the patient's name, birth date, and the names of agencies or individuals involved are all clearly filled out.
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Incorrect Dates: People often make errors when entering dates. Double-check that the dates for the requested information and the authorization period are accurate.
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Not Specifying Purpose: It’s important to clearly state the purpose for the release of information. Leaving this section blank can result in the form being rejected or delayed.
Documents used along the form
The California MH 5671 form is a crucial document for authorizing the release of confidential patient information related to mental health services. Alongside this form, several other documents may be required to ensure compliance with legal and procedural standards. Here’s a list of some of those important forms and documents.
- HIPAA Privacy Notice: This document informs patients about their rights regarding the privacy of their health information. It outlines how their information may be used and shared, ensuring transparency in handling sensitive data.
- Patient Consent Form: This form is used to obtain explicit consent from the patient before any information is shared. It details what information will be shared, with whom, and for what purpose, ensuring that the patient is fully informed.
- Release of Information (ROI) Form: Similar to the MH 5671, this form specifically authorizes the release of medical records. It may be used in various healthcare settings, emphasizing the importance of patient consent in sharing their information.
- Assessment and Treatment Plan: This document outlines the patient’s mental health assessment and the proposed treatment plan. It serves as a guide for care providers and is often shared with other professionals involved in the patient’s care.
- Discharge Summary: This summary provides a comprehensive overview of the patient's treatment and progress upon discharge from a mental health facility. It includes recommendations for ongoing care and is essential for continuity of treatment.
- Legal Documentation: This may include court orders or guardianship papers that affect the patient's rights and decisions regarding their mental health care. Such documents are crucial for ensuring that legal requirements are met.
- Insurance Authorization Form: This form is used to obtain approval from an insurance provider for specific mental health services. It ensures that the necessary coverage is in place before treatment begins.
- Patient Identification Form: This document collects basic demographic and identification information about the patient. It is essential for maintaining accurate records and ensuring proper identification in treatment settings.
Understanding these documents can help patients and their families navigate the complexities of mental health care. Each form plays a vital role in protecting patient rights and ensuring that care is delivered effectively and ethically.
Similar forms
The California MH 5671 form is designed to authorize the release of confidential patient information related to mental health services. This form shares similarities with other documents that also facilitate the release of medical or personal information. Below are four such documents:
- HIPAA Authorization Form: This form allows individuals to authorize the release of their protected health information to specific parties. Like the MH 5671, it requires the patient's signature and outlines what information will be shared and with whom.
- Patient Information Release Form: This document is used in various healthcare settings to obtain permission from patients to share their medical records. Similar to the MH 5671, it specifies the information to be released and the purpose of the disclosure.
- Consent for Treatment Form: This form is used to obtain a patient’s consent for treatment and may include authorization for sharing relevant medical information with other healthcare providers. Both forms emphasize the patient's right to refuse and the importance of informed consent.
- Release of Information (ROI) Form: Common in healthcare, this form is utilized to obtain permission to release specific medical records. It, too, requires patient or guardian signatures and details what information is being disclosed, similar to the structure of the MH 5671.
Dos and Don'ts
When filling out the California MH 5671 form, it is essential to follow specific guidelines to ensure that the process is smooth and compliant with regulations. Below is a list of things you should and shouldn't do:
- Do ensure that all required fields are completed. This includes the patient’s name, birth date, and the names of the individuals or organizations involved.
- Do obtain the necessary signatures. Make sure that the patient, or their parent/guardian/conservator, signs the form. If the patient signs, a witness signature is also required.
- Do specify the purpose of the information release. Clearly indicate whether the information is needed for evaluation, treatment planning, or another purpose.
- Do limit the information disclosed. Only include the types of information that are necessary for the stated purpose, and ensure that the date range is accurate.
- Don't leave any sections blank. Each part of the form must be filled out completely to avoid delays or rejections.
- Don't forget to provide a copy of the authorization. The patient has the right to receive a copy of the signed authorization for their records.
By adhering to these guidelines, individuals can help facilitate the proper handling of sensitive patient information while complying with legal requirements.
Misconceptions
Misconceptions about the California MH 5671 form can lead to confusion regarding its purpose and use. Here are four common misunderstandings:
- It is mandatory to use the MH 5671 form for all patient information requests. Many believe that this form is required for every request. However, if the request is a facsimile of the form or contains all necessary information, the form may not be needed.
- Signing the form is compulsory for treatment. Some individuals think that treatment can be denied if they do not sign the authorization. In reality, the hospital cannot condition treatment or payment on the authorization being signed.
- The patient has no control over the information released. There is a misconception that once the form is signed, the patient has no say in what is shared. In fact, the patient can specify which information is to be released and can revoke the authorization at any time.
- The authorization lasts indefinitely. It is often assumed that the authorization remains valid forever. However, the form specifies a termination period, typically six months or one year, after which the authorization expires unless renewed.
Understanding these points can help individuals navigate the process more effectively and ensure their rights are protected.
Key takeaways
Understand the Purpose: The California MH 5671 form is used to authorize the release of confidential patient information, particularly related to mental health services.
Who Signs: The patient, or their parent, guardian, or conservator, must sign the form. If the patient signs, a witness signature is also needed.
Information to be Released: Clearly specify what information is being released. This includes details like diagnoses, treatment plans, and any evaluations.
Limitations on Release: The hospital cannot condition treatment or payment on signing the authorization. Patients can refuse to sign, and information will not be released unless required by law.
Duration of Authorization: The authorization remains valid for a specified period, which can be six months, one year, or until a specified date. It can be revoked in writing at any time.
Right to Inspect: Patients have the right to inspect or obtain a copy of the protected health information that will be disclosed under this authorization.