The Mental Health Release Form is a critical document used in Canadian healthcare settings to facilitate the authorized sharing of sensitive mental health information while maintaining patient privacy rights. This form becomes necessary when mental health information needs to be shared between healthcare providers, with insurance companies, or with other authorized parties. It must comply with federal privacy legislation (PIPEDA) as well as provincial health information protection acts and mental health regulations. The document includes specific provisions for consent, information specification, duration of authorization, and patient rights, reflecting the careful balance between information sharing needs and privacy protection in mental health care contexts. Healthcare providers must ensure this form is properly completed and documented to maintain compliance with Canadian privacy laws and professional standards.
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1. Patient Information: Complete identification of the patient including full name, date of birth, address, and contact information
2. Healthcare Provider Information: Details of the healthcare provider or facility releasing the information
3. Information to be Released: Specific description of what mental health records and information are authorized for release
4. Purpose of Release: Clear statement of why the information is being released and how it will be used
5. Duration of Authorization: Timeframe for which the release authorization is valid
6. Recipient Information: Complete details of who is authorized to receive the information
7. Rights and Notices: Statement of patient's rights regarding the release, including right to revoke and any limitations
8. Privacy Statement: Description of how information will be protected and privacy maintained
9. Signature and Date: Space for patient or authorized representative signature, date, and witness if required
1. Substitute Decision Maker Authorization: Required when someone other than the patient is authorizing the release
2. Specific Exclusions: Section detailing any specific information that should NOT be released
3. Emergency Contact Information: Contact details for emergencies, included when form is part of ongoing treatment
4. Electronic Distribution Authorization: Specific permission for electronic transmission of records
5. Fee Schedule: Information about any applicable fees for record copying or transmission
6. Research Authorization: Additional permissions for use of information in research, if applicable
7. Revocation Instructions: Detailed process for revoking the authorization before expiration
1. Schedule A - Types of Information: Detailed list of all types of mental health information that may be released
2. Schedule B - Privacy Policy: Full privacy policy and information handling procedures
3. Schedule C - Patient Rights: Comprehensive explanation of patient rights regarding their mental health information
4. Appendix 1 - Glossary: Definitions of medical and legal terms used in the document
5. Appendix 2 - Jurisdictional Requirements: Specific requirements based on provincial/territorial laws
6. Appendix 3 - Contact List: List of relevant contacts including privacy officers and mental health advocates
Relevant legal definitions
Personal Health Information
Mental Health Records
Protected Information
Healthcare Provider
Mental Health Professional
Authorized Representative
Substitute Decision Maker
Capacity
Consent
Release Authorization
Treatment Information
Clinical Notes
Disclosure
Confidentiality
Privacy
Health Information Custodian
Recipients
Revocation
Electronic Health Record
Progress Notes
Psychological Assessment
Psychiatric Evaluation
Treatment Plan
Medical Emergency
Express Consent
Implied Consent
Personal Representative
Third Party
Record Retention Period
Information Blocking
Mental Health Records
Protected Information
Healthcare Provider
Mental Health Professional
Authorized Representative
Substitute Decision Maker
Capacity
Consent
Release Authorization
Treatment Information
Clinical Notes
Disclosure
Confidentiality
Privacy
Health Information Custodian
Recipients
Revocation
Electronic Health Record
Progress Notes
Psychological Assessment
Psychiatric Evaluation
Treatment Plan
Medical Emergency
Express Consent
Implied Consent
Personal Representative
Third Party
Record Retention Period
Information Blocking
Clauses
Information Disclosure
Privacy Protection
Consent
Authorization Period
Revocation Rights
Information Security
Patient Rights
Liability
Confidentiality
Data Protection
Record Access
Emergency Provisions
Third Party Disclosure
Electronic Transmission
Information Storage
Documentation Requirements
Regulatory Compliance
Governing Law
Dispute Resolution
Witness Requirements
Privacy Protection
Consent
Authorization Period
Revocation Rights
Information Security
Patient Rights
Liability
Confidentiality
Data Protection
Record Access
Emergency Provisions
Third Party Disclosure
Electronic Transmission
Information Storage
Documentation Requirements
Regulatory Compliance
Governing Law
Dispute Resolution
Witness Requirements
Relevant Industries
Healthcare
Mental Health Services
Medical Administration
Legal Services
Social Services
Insurance
Education
Research & Development
Public Health
Relevant Teams
Legal
Compliance
Medical Records
Mental Health Services
Privacy & Data Protection
Patient Services
Risk Management
Quality Assurance
Healthcare Administration
Clinical Operations
Relevant Roles
Mental Health Professional
Psychiatrist
Psychologist
Clinical Social Worker
Healthcare Administrator
Medical Records Manager
Privacy Officer
Compliance Officer
Legal Counsel
Healthcare Director
Mental Health Nurse
Patient Care Coordinator
Medical Office Manager
Risk Management Officer
Quality Assurance Specialist
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