Release of Information Instructions

Authorization Options

Release to: Authorization is to release information only to the identified person

Obtain from: Authorization is to obtain information from another source

Exchange with: Authorizes the two designated parties to share information. This option provides the greatest flexibility for communication.

The purpose of releasing this information is: (The following are examples)

To show (designated person) that I am or have been in counseling So that I may have a copy of my treatment records To send records to a new care provider (transfer of care) or consultant

Authorizations Sent to or Received by the Mental Health Services by Fax

Authorizations for the Mental Health Services to release or obtain information received by fax will be accepted if a signature verification can be made from the client’s file or from another source. Other acceptable sources that must accompany the fax request include: 1) This form signed in the presence of, and notarized by, a Notary Public; or 2) a copy of a valid driver’s license with photo or Texas A&M University ID card; or 3) a copy of another government issued document containing a valid photo, such as an identification card or a passport so Mental Health Services can verify your identity.

Guidelines for Clients to Review and/or Obtain a Copy of Their File

State of Texas law specifies the procedure by which patients/clients may obtain a copy of their records. The procedure is reproduced verbatim below.

No later than 15 days after receiving a written request from a patient to examine or copy all or part of the patient’s mental health records, a clinician shall:

A. Make the information available during regular business hours and provide a copy to the patient, if requested; or B. Inform the patient in writing that the information does not exist or cannot be found; or C. Provide the patient with a signed and dated statement that having access to the mental health records would be harmful to the patient’s physical, mental, or emotional health. The written statement must specify the portion of the record being withheld, the reason for the denial and the duration of the denial. However, these records may still be released to another practicing professional.

The Mental Health Services adheres to Texas law in complying with the procedure specified for clients to review and obtain a copy of their record. In addition, it is the policy of the Mental Health Services for patients/clients to review their record with a professional staff member so that questions can be answered and clarification provided as needed. This may be done by an in-person or telephone appointment. If you wish to review your records with a professional staff member, please contact our front desk (979-845-4427) so we may arrange for you to do so.

To initiate this process, a client must complete the Mental Health Services Authorization to Release/Obtain/Exchange Confidential Information form. If this form is completed at the Mental Health Services, the authorization signature must be witnessed by an Mental Health Services employee and accompanied by identity verification. If the form is not completed at the Mental Health Services, it must be accompanied by one of the following: 1) Witnessed by a Notary Public; 2) accompanied by a copy of a valid driver’s license with photo or Texas A&M University ID card, or 3) accompanied by a copy of another government issued document containing a valid photo, such as an identification card or a passport so Mental Health Services can verify your identity.

All submissions will be sent to our case management coordinator Hannah Kovar.