CAREGIVER REQUEST FOR DISCLOSURE OF INFORMATION

Current through 2022-14, April 6, 2022

(You may use additional paper for explanations)

Name of person making request (your name):___________________________________

Address:___________________________________________________________________

Telephone:_________________________________________________________________

Name of Licensed Mental Health professional from whom you are requesting information:__________________

Agency___________________________________________________________

Address:__________________________________________________________

Phone:___________________________________________________________

I wish information regarding:___________________________________________

___________________________________________________________________

Name:_____________________________________________________________

DOB:________________________________________________________________

Address:______________________________________________________________

Phone:________________________________________________________________

My relationship to the person is:___________________________________

Do you live with the person" YES NO

If you do not live with the person, what direct care do you provide them (describe)"_____________

__________________________________________________________-

Do you receive payment for providing direct care to this person" YES NO

I request that you provide the following information (check information you wish to be disclosed).

[] Diagnosis.

[] Behavioral management strategies I may be able to assist with.

[] Treatment plan and goals that relate to the direct care I provide.

[] Medications prescribed, side effects and likely consequences of not taking it as prescribed. (over)

The following state regulations pages link to this page.



State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.