MDHHS-5515 (Rev. 12-18) 2
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.
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:
Section 3: What Information You Want to Share
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.
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.