Authorization to Use and Disclose Protected Health Information

The Health Information Portability and Accountability Act (HIPAA) of 1996 established national standards for the use and disclosure of a person's protected health information. To specifically define the rights that individuals have to control the use and disclosure of their protected health information, the U.S. Department of Health and Human Services issued the Privacy Rule. The Arizona Department of Health Services/Division of Behavioral Health Services (ADHS/DBHS), Cenpatico Behavioral Health of Arizona, and behavioral health providers must all comply with the Privacy Rule when providing health care services and/or paying for services with state and federal funds. Cenpatico's Release of Information forms meet the Privacy Rule requirements established by HIPAA and guide the use and disclosure of specific protected health information. Provider agencies may utilize any and all Release of Information (ROI) forms found on this page. For additional information, please reference the Cenpatico Integrated Care Provider Manual.

Please note that releases used to authorize the sharing of:

  • Psychotherapy Notes, (45 CFR 164.508)
  • Substance Abuse Treatment Information, (42 CFR, Part 2)
  • HIV/AIDS Status and Treatment, (ARS 36-664)
  • Sickle-cell Anemia, or
  • Other Gene Related Impairments

Cannot be combined with another authorization and should be maintained separately and distinctly from authorizations generally releasing PHI in accordance with 45 CFR 164.508.

Cenpatico of Arizona Release of Information Forms

Authorization for Psychotherapy Notes Only

Generic Release of Information Forms

Authorization for Substance Abuse Information