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DMH Privacy Forms

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These forms may be used by individuals who wish to communicate with the Department of Mental Health to authorize the release of, or amend, restrict, or request access to their protected health information. The forms may be downloaded and printed as needed. 

DMH Privacy Forms

• English Version (PDF) l Word

• Arabic Version (PDF) l Word

• Chinese Version (PDF) l Word

• Haitian Version (PDF) l Word

• Khmer Version (PDF) l Word

• Portuguese Version (PDF) l Word

• Russian Version (PDF) l Word

• Spanish Version (PDF) l Word

• Vietnamese Version (PDF) l Word

• Authorization Form-One Way From DMH (PDF) l Word 

• Authorization Form-One Way To DMH (PDF) l Word

• Authorization Form-Two Way  (PDF) l Word 

• Authorization Form-Two Way (Chinese) (PDF) l Word

• Authorization Form-Two Way (Haitian) (PDF) l Word

• Authorization Form-Two Way (Khmer) (PDF) 

• Authorization Form-Two Way (Portuguese) (PDF) l Word

• Authorization Form-Two Way (Russian) (PDF) l Word

• Authorization Form-Two Way (Spanish) (PDF) l Word

• Authorization Form-Two Way (Vietnamese) (PDF) l Word

• Authorization For Benefits (PDF) l Word

• Authorization For Photo, Audio, Video (PDF) l Word

• Authorization For Revocation (PDF) l Word

• Authorization to Inspect PHI (PDF) l Word

• Authorization to Amend PHI (PDF) l Word

• Audit Trail Request Form (PDF) l Word

• Confidential Communications Request (PDF) l Word

• Restriction Request Form (PDF) l Word

• Privacy Complaint (PDF) l Word

• HIPAA L-14 - Confidentiality Acknowledgment Form (PDF) l Word

 

 

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This information is provided by the  Department of Mental Health