Solari ROI

Solari ROI
AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
Section 1: Purpose of the Use or Disclosure of Protected Health Information The purpose of this Authorization for Use and Disclosure of Protected Health Information is to allow health care providers to disclose protected health information to Solari so that the Solari may evaluate my eligibility to receive Serious Mental Illness (SMI) services. Federal and state law prohibits health care providers from sharing my health information without my permission except in certain situations. By signing this Authorization, I am giving permission for my health care providers to share my health information with Solari. Section 2: Applicant whose Health Information is to be Used or Disclosed
Name

First NameMiddle InitialLast Name
Email
example@example.com
Social Security Number
Date of Birth

MonthDayYear
Date
Phone Number (with area code)
Please enter a valid phone number.
Address

Address

Street Address Line 2

CityState

Zip Code
Section 3: Providers Directed to Uscor Disclose Protected Health Information
Healthcare Provider Name 1
Address

Address

Street Address Line 2

City, State, and Zip CodeState / Province

Postal / Zip Code
Agency Phone Number (with area code)
Healthcare Provider Name 2
Address

Address

Street Address Line 2

City. State. and Zip CodeState / Province

Postal / Zip Code
Agency Phone Number (with area code)
Healthcare Provider Name 3
Address

Address

Street Address Line 2

City, State, and Zip CodeState / Province

Postal / Zip Code
Agency Phone Number (with area code)
[insert additional sheets if necessary]

Section 4: Health Information to be Used or Disclosed

I hereby authorize the use and disclosure of my health information needed to evaluate my eligibility to receive Serious Mental Illness (SMI) services. In addition to my general medical record information (e.g., prescriptions, consultations, provider notes, hospital records, etc, I understand that this may include disclosure of my mental health. behavioral health, alcohol and other drug abuse treatment. and developmental disability information. including diagnosis, treatment plans, prognosis, and medication(s).

Crisis Response Network, Inc. 1275 W. Washington, Suite 201 Tempe. AZ 85281 Last Revised: 3/11/21

Toll Free: 1-855-832-2866 www.crisisnetwork.org
Further, I authorize the use and disclosure of my:
HIV-related information:

YESNO
Other communicable disease related information:

YESNO
Genetic information:

YESNO
For the Following Date(s):
Section 5: Expiration of this Authorization
This Authorization will remain effective for one year from the date it is signed unless I designate a specific expiration date, even, or condition here:
Section 6: Revocation of this Authorization

I understand that I may revoke this Authorization at any time by writing to Solari at 1275 W. Washington, Suite 201, Tempe, Arizona 85281. The revocation will be effective except to the extent that Solari has already used or disclosed my health information in reliance on this Authorization

Section 7: Rights and Notices

I understand the following:

- Signing this Authorization is voluntary. My treatment, payment, enrollment or eligibility for benefits will not be conditioned on signing this Authorization.

- My information disclosed pursuant to this Authorization is subject to redisclosure by the recipient and may no longer be protected by the terms of this Authorization or by federal and state privacy regulations. All disclosures of my health information protected by federal regulation 42 CFR Part 2 will be accompanied by a notice informing the recipient that redisclosure of the information is prohibited except as permitted by law.

I must be provided a copy of this signed Authorization

Section 8: Authorization of Applicant/Legs Representative
Applicant Signature

Clear
Date of Signature

MonthDayYear
Date
Legal Representative Signature (if applicable)

Clear
Date of signature

MonthDayYear
Date
This Applicant is:

a minorLegally incompetent or incapacitateddeceased
Legal authority

parentlegal guardiannext of kin/executor of deceasedactivated POA for health care
* If Applicant is under 18 years of age, both his/her signature is preferred along with required signature of parent/legal guardian.
Healthcare Provider's Email*
example@example.com
Should be Empty:

Solari ROI

AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION