STATE OF DELAWARE 

DEPARTMENT OF HEALTH AND SOCIAL SERVICES 

DIVISION OF SUBSTANCE ABUSE AND MENTAL HEALTH 

AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION 

________________________________________________________________________________________________________ 

In compliance with Federal Regulations (42 U.S.C. 4582 and 21 U.S.C. 1175) and the Health 
Insurance Portability and Accountability Act (HIPAA) of 1996 (45 C.F.R. Pts. 160 and 164) 

 

Client Name: _________________________________DOB: _____________ 

SS#: _____________________ 

I, the undersigned, hereby authorize the Eligibility & Enrollment Unit to disclose to the 
following entities: 

 

• Brandywine Counseling, Inc. 
• Brandywine Hills (RHD) 
• Connections CSP. (CCCP/Meadows Res./Blackbird Group Home) 
• Delaware Psychiatric Center 
• Division of Vocational Rehabilitation 
• Fellowship Health Resources (CCCP,Georgetown Group Home/ Hope House Group Home/ Taton Group Home) 
• Gateway Foundation 
• Gaudenzia 
• Horizon House (CCCP/ Bennett House/ Wilson House/ Old Balt. Pike) 
• Limen House 
• Now Group Home (RHD) 
• Psychotherapeutic Services, Inc. (CCCP, Felton Group Home) 
• Other: 


 

the following information: the Eligibility & Enrollment Application Packet, ASI, Assessment Summary, ASAM 
Summary, Consumer Reporting Forms (pages 1 & 2), Eligibility & Enrollment Summary Sheet and the 
S.E.T. Service Authorization Form. 

 

The purpose or need for this disclosure is to coordinate behavioral health care treatment. 


I understand that my records are protected under federal regulations governing Confidentiality of Alcohol 
and Drug Abuse Patient Records, 42 CFR Part 2, and the Health Insurance Portability and Accountability 
Act of 1996 ("HIPAA"), 45 C.F.R. Pts. 160 and 164 and cannot be disclosed without my written consent 
unless otherwise provided for in the regulations. I also understand that I may revoke this consent in 
writing at any time except to the extent that action has been taken in reliance on it. I understand that my 
private health information, once disclosed to others, may be redisclosed to individuals or organizations 
not subject to HIPAA and may no longer be protected by HIPAA. I understand that generally DSAMH 
may not condition my treatment on whether I sign an authorization form, but that in certain limited 
circumstances I may be denied treatment if I do not sign an authorization form. 

This consent extends from this date until 60 days post discharge from DSAMH/Contracted services. 

 

 

Signed___________________________________________ Date _______________ 

 

__________________________________________________ 

 (Relationship if signed by other than client)