MDHHS-5515 (Rev. 12-18) 1
Previous edition obsolete.
CONSENT TO SHARE BEHAVIORAL HEALTH INFORMATION
Michigan Department of Health and Human Services
Use this form to give or take away your consent to share information about your:
• Mental and behavioral health services. This will be referred to as “behavioral health”
throughout this form.
• Diagnosis, referral, and treatment for an alcohol or substance use disorder. This will be
referred to as “substance use disorder” throughout this form.
This information will be shared to help diagnose, treat, manage, and pay for your health
needs.
Why This Form Is Needed
When you receive health care, your health care provider and health plan keep records
about your health and the services you receive. This information becomes a part of your
medical record. Under state and federal laws, your health care provider and health plan do
not need your consent to share most types of your health information to treat you,
coordinate your care, or get paid for your care. But they may need your consent to share
your behavioral health or substance use disorder records.
Instructions
• To give consent, fill out Sections 1, 2, 3, and 4.
• To take away consent, fill out Sections 5.
• Sign the completed form, then give it to your health care provider. They can make a
copy for you.
Section 1: About You
First Name
Middle
Initial
Last Name
Date of Birth
Date Signed
Section 2: Who Can See Your Information and How They Can Share It
Section 2a: Sharing Information Between Individuals and Organizations
Let us know who can see and share your behavioral health and substance use disorder
records. You should list the specific names of health care providers, health plans, family
members, or others. They can only share your records with people or organizations listed
below.
1.
4.
2.
5.
3.
6.
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Previous edition obsolete.
Section 2b: Sharing Information Electronically
Health information exchanges or networks share records back and forth electronically. This
type of sharing helps the people involved in your health care. It helps them provide better,
faster, safer, and more complete care for you. Your health care provider and health plan
may have already listed these organizations below.
Choose only one option:
Share my information through the organizations listed below. This information will be
shared with the individuals and organizations listed under Section 2a.
Do not share my information through the organizations listed below.
Share my information through the organizations listed below with all of my past, current,
and future treating providers. If I choose this option, I can request a list of providers who
have seen my records.
For Health Care Provider or Health Plan Use Only. List all health information exchanges
or networks:
1.
4.
2.
5.
3.
6.
Section 3: What Information You Want to Share
Choose one option:
Share all my behavioral health and substance use disorder records. This does not
include “psychotherapy notes.”
Share only the types of behavioral health and substance use disorder records listed
below. For example, what I am being treated for, my medications, lab results, etc.
1.
4.
2.
5.
3.
6.
Section 4: Your Consent and Signature
Read the statements below, then sign and date the form.
By signing this form below, I understand:
• I am giving consent to share my behavioral health and substance use disorder records.
This includes referrals and services for alcohol and substance use disorders, but other
information may also be shared.
• I do not have to fill out this form. If I do not fill it out, I can still get treatment, health
insurance or benefits. But, without this form, my provider or health plan may not have all
the information needed to treat me.
• My records listed above in Section 3 will be shared to help diagnose, treat, manage,
and pay for my health needs.
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Previous edition obsolete.
• My records may be shared with the people or organizations as stated in Section 2.
• Other types of my health information may be shared along with my behavioral health
and substance use disorder records. Under existing laws, my health care provider and
health plan do not need my consent to share most types of my health information to
treat me, coordinate my care or get paid for care.
• This form does not give my consent to share “psychotherapy notes”.
• I can remove my consent to share behavioral health and substance use disorder
records at any time. I understand that any records already shared because of past
approval cannot be taken back. I should tell all individuals and organizations listed on
this form if I remove my consent.
• I have read this form. Or it has been read to me in a language I can understand. My
questions about this form have been answered. I can have a copy of this form.
• This signature is good for 1 year from the date signed. Or I can choose an earlier date
or have it end after the event or condition listed below. (For example, at the end of my
treatment.)
Date, event, or condition:
State your relationship to the person giving consent and then sign and date below:
Self
Parent (Print Name)
Guardian (Print Name)
Authorized Representative (Print Name)
Signature
Date
Witness Signature (If Appropriate)
Date
TAKE AWAY YOUR CONSENT
Complete Section 5 if you no longer want to share your records listed above in Section 3.
Section 5: Who Can No Longer See Your Information
I no longer want to share my records with those listed in Sections 2a and 2b. I understand
any information already shared because of past approval cannot be taken back.
State your relationship to the person withdrawing consent, then sign and date below.
Self
Parent (Print Name)
Guardian (Print Name)
Authorized Representative (Print Name)
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Signature
Date
Witness Signature (If Appropriate)
Date
FOR HEALTH CARE PROVIDER OR HEALTH PLAN USE ONLY
Verbal Withdrawal of Consent
The individual listed above in Section 1 has taken away his/her consent.
List the individual who requested the withdrawal below, then sign and date below.
Individual listed above in Section 1.
Parent (Print Name)
Guardian (Print Name)
Authorized Representative (Print Name)
Signature of Person Who Received
the Verbal Withdrawal
Print Name
Date
Other Information for Health Care Providers and Health Plans
This form cannot be used for a release of information from any person or agency that has
provided services for domestic violence, sexual assault, stalking, or other crimes. See the
FAQ for providers and other organizations at michigan.gov/bhconsent.
Additional Identifiers (Optional)
Medicaid
Last 4 of the Social Security Number
Form Copy (Optional, Choose One Option)
The individual in Section 1 received a copy of this form.
The individual in Section 1 declined a copy of this form.
AUTHORITY:
This form is acceptable to the Michigan Department of Health and Human
Services as compliant with 42 CFR Part 2, PA 258 of 1974 and
MCL 330.1748 and PA 368 of 1978, MCL 333.1101 et seq. and PA 129
of 2014, MCL 330.1141a.
COMPLETION:
Is Voluntary, but required if disclosure is requested.
The Michigan Department of Health and Human Services (MDHHS) does not discriminate
against any individual or group because of race, religion, age, national origin, color, height,
weight, marital status, genetic information, sex, sexual orientation, gender identity or
expression, political beliefs or disability.
