DMH Privacy Forms

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.

Authorization Forms

One Way Form Release of Information Forms

• Authorization Form-One Way From DMH (PDF) 
• Authorization Form-One Way To DMH (PDF) 

Two Way Release of Information Forms

• Authorization Form-Two Way (PDF) 
• Authorization Form-Two Way (Chinese) (PDF) 
• Authorization Form-Two Way (Haitian) (PDF) 
• Authorization Form-Two Way (Khmer) (PDF) 
• Authorization Form-Two Way (Portuguese) (PDF) 
• Authorization Form-Two Way (Russian) (PDF) 
• Authorization Form-Two Way (Spanish) (PDF) 
• Authorization Form-Two Way (Vietnamese) (PDF) 

Other Authorization Forms

• Authorization For Benefits (PDF) 
• Authorization For Photo, Audio, Video (PDF) 
• Authorization For Revocation (PDF) 
• Authorization to Inspect PHI (PDF) 
• Authorization to Amend PHI (PDF) 

Additional Forms

• Audit Trail Request Form (PDF) 
• Confidential Communications Request (PDF) 
• Restriction Request Form (PDF) 
• Privacy Complaint (PDF) 
• HIPAA L-14 - Confidentiality Acknowledgment Form (PDF) 

 

 

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This information is provided by the Department of Mental Health