District Of Columbia § 7-1202.02 - Form of authorization.

Specify the nature of the information to be disclosed, the type of persons authorized to disclose such information, to whom the information may be disclosed and the specific purposes for which the information may be used both at the time of the disclosure and at any time in the future;

Advise the client of his right to inspect his record of mental health information;

State that the consent is subject to revocation, except where an authorization is executed in connection with a client’s obtaining a life or noncancellable or guaranteed renewable health insurance policy, in which case the authorization shall be specific as to its expiration date which shall not exceed 2 years from the date of the policy; or where an authorization is executed in connection with the client’s obtaining any other form of health insurance in which case the authorization shall be specific as to its expiration date which shall not exceed 1 year from the date of the policy;

Be signed by the person or persons authorizing the disclosure; and

Contain the date upon which the authorization was signed and the date on which the authorization will expire, which shall be no longer than 365 days from the date of authorization.

Be provided to the client and the person authorizing the disclosure;

Accompany all such disclosures; and

Be included in the client’s record of mental health information.