Department of Health and Human Services
Behavioral Health
HIPAA Forms - Consent for Purposes of Treatment, Payment
and Healthcare Operations
_________________________
Consumer's Name
This consent form may be used ONLY for Department of Behavioral and Developmental Services (BDS)
- adult mental health intensive case management services;
- adult mental retardation case management services;
- adult mental retardation crisis services;
- admission to Aroostook Residential Center, Elizabeth Levinson Center, Freeport Towne Square.
Any other use makes this consent invalid.
I consent to the use or disclosure of my protected health information by
______________________ for the purpose of providing services to me, obtaining
payment for bills for services I receive, or to conduct health care operations.
My protected health information means health information, including information that identifies me, that I have provided.
It also means information that service providers have created about me and information that has been shared about me.
This protected health information includes my past, present or future health or condition or services. It includes
information that could be used to identify me even if my name is not used.
I have been provided a copy of the Notice of Privacy Practices. I understand that I have a right to review the notice
before signing this form. I understand that BDS can change the notice and their privacy practices. I can get a copy of the
changed notice by contacting _________________________________. I understand that the notice is posted
in _______________________________________________ and on the web page for BDS
http://www.maine.gov/dhhs/bh/HIPAA/PrivacyNotice/Privacy.html
I understand that I have the right to ask for restrictions on how my protected health information is used. I understand
that BDS does not have to agree with the restrictions I ask for.
___________________________________________________________________
My Signature Date
___________________________________________________________________
Signature/Relationship of Personal Representative Date
___________________________________________________________________
Witness Date
