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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.

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One Way Release of Information Forms

Open PDF file, 231.04 KB,  Authorization Form-One Way From DMH (English, PDF 231.04 KB)
Open PDF file, 230.05 KB,  Authorization Form-One Way To DMH (English, PDF 230.05 KB)

Two Way Release of Information General Use Forms

Open PDF file, 257.93 KB,  Authorization Form General Use - Two Way (English, PDF 257.93 KB)

Two Way Release of Psychotherapy Notes Forms

Open PDF file, 201.19 KB,  Authorization Form Psychotherapy Notes - Two Way (English, PDF 201.19 KB)

Additional Authorization Forms

Authorization For Photo, Audio, Video (PDF)
Authorization for Photo, Video, Audio (Spanish)
Release of Information for Social Supports

Additional Privacy Forms

Revocation of Authorization (PDF)
Request to Inspect PHI (PDF)
Request to Amend PHI (PDF)
Audit Trail Request Form (PDF)
Confidential Communications Request (PDF)
Restriction Request Form (PDF)
Privacy Complaint (PDF)
Attestation Regarding a Requested Use or Disclosure of Protected Health Information Potentially Related to Reproductive Health Care (PDF)

Recovery From Addictions Program (RAP) Forms

RAP Authorization for Release of Information Two-Way
RAP Authorization for Release of Substance Use Disorder Counseling Notes
RAP Authorization for Release of Records for Legal Proceedings
RAP Substance Use Disorder Re-Disclosure Notice

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